Midterm Scenario Lab 3 (final)

Alfred Angeles Midterm Senario 2007 June 11 1.) Your client is a 24-year-old female, who had a hysterectomy seven days ago. She has a 10cm incision right lower quadrant to left lower quadrant. The incision has been closed with staples. She has a saline loc in place on her left hand. At present she has pain only when sitting down. Ms. Underhill is non-compliant with leg exercises. She requires assistance to ambulate. She is complaining of left sided abdominal pain. The nurses’ notes indicate she has not had a bowel movement in 4 days. DR’s Orders: Remove alternating staples today Tylenol #3, 2 tablets po Q4H PRN Soft Diet to full diet

Nursing Diagnosis: 1)Acute pain related to surgical incision as evidenced by patient’s complain of pain when sitting down. 2)Risk for injury related to altered mobility evidenced by requiring assistance to ambulate. 3)Constipation related to surgery as evidenced by absence of bowel movement in 4 days after surgery.

Nursing Intervention: 1)Administer pain medication as ordered. 2)Put the bed on the lowest position, side rails up and call bell within reach when patient is in bed. 3)Encourage patient to increase fluid intake and walk. Brand/Trade Name: Tylenol Acetaminophen Drug Classification: Analgesic

Drug Action/effect: May block pain impulses peripherally that occurs in response to inhibition or prostaglandin synthesis; does not possess anti-inflammatory properties; antipyretic action results from inhibition of prostaglandins in the CNS (hypothalamic heat-regulating center); decreased pain, fever. Safe Dosage and route: •

Adult and child > 10 yr. PO 325-650 mg q4h prn, not to exceed 4g/day; REC 325650 mg q4h prn, not to exceed 4g/day.

•

Administer to patient crushed or whole; chewable tabs may be chewed.

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Give with food or milk to decrease gastric symptoms; give 30 mins. Before or 2 hr after meals, absoption may be slowed.

Side effects/Adverse effects: • • • • • •

CNS: Stimulation, drowsiness GI: Nausea, vomiting, abdominal pain, hepatotoxicity HEMA: Leukopenia, neutropenia, hemolytic anemia, thrombocytopenia INTEG: rash, urticaria, angioedema SYST: Anaphylaxis TOXICITY: Cyanosis, anemia, jaundice, CNS stimulation, delirium followed by vascular collapse, convulsions, coma, death

Contraindications: Hypersensivity, intolerance to tartrazine (yellow dye no. 5), alcohol, table sugar, saccharin. Precautions: Anemia, hepatic disease, renal disease, chronic alcoholism, pregnancy Nursing considerations/client teaching: Assessment: • • •

Monitor liver function studies: AST, ALT bilirubin, creatinine before therapy if long-term therapy is anticipated. Monitor renal function studies: BUN, urine creatinine, occult blood, albumin indicates nephritis. Monitor blood studies: CBC, pro-time if patient is on long-term therapy.

• • • • • •

Check I&O ratio, decreasing output may indicate renal failure Assess for fever and pain, type of pain, location, intensity, duration, temperature, diaphoresis. Assess mucosa, fingernail, beds for cyanosis, inquire about dyspnea, vertigo, headache, weakness Assess for chronic poisoning: rapid, weak pulse, dyspnea, cold clammy extremities; report immediately. Assess hepatotoxicity: dark urine, clay-colored stools, yellowing of skin and sclera; itching, abdominal pain, fever, diarrhea if patient is on long term therapy. Assess allergic reaction: rash, urticaria, if these occur, drug may have to be discontinued.

Pregnancy risk category: Patient education: •

Teach patient not to exceed recommended dosage, acute poisoning with lever damage may result; acute toxicity includes symptoms of nausea, vomiting, and abdominal pain

•

Tell patient to read label on other OTC drugs; many contain acetaminophen and may cause toxicity if taken concurrently.

•

Teach patient to recognize signs of chronic overdose; bleeding, bruising, malaise, fever, sore throat.

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Inform patient that urine may become dark brown as a result of phenacetin (metabolite of acetaminophen).

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Tell patient to notify prescriber for pain or fever lasting over 3 days.

Scenario 2: Tom Brown Your client is an 18-year-old male – 1 day post-operative following a ruptured appendix surgery. He has a 5cm. incision on the right lower quadrant closed with interrupted sutures. He has a Jackson-Pratt drain in place at the end of the incision line closest to the patients’ midline. There is a moderate amount of serosanquinious exudates in the container. His temperature has been elevated off & on over the past 24 hours and is currently 38 degrees. He has an intravenous infusion of normal saline 0.9% running at 100ml./hr. At present he has mild abdominal pain, one half hour after his Morphine. DR’s Orders:

Change dressing daily Remove Jackson- Pratt today Morphine 5-10 mg IM or po q4h prn IV Ancef 1 gm Q8H Monitor Temp Q4H IV Normal Saline 0.9% @ 100ml./hr. Full fluid to Soft Diet Nursing diagnosis: 1) Infection related to surgery as evidenced by elevated temperature off and on over the past 24 hrs and currently 38 degrees. 2) Acute pain related to surgical incision as evidenced by complain of mild pain. 3) Risk for constipation related to morphine as evidenced by absence of BM 24 hrs after surgery. Nursing intervention: 1) Administer anti-infective agent (ancef) as ordered. Encourage patient to eat foods rich in vitamin c to strengthen the immune system. 2) Assess COLDSPA. Administer pain medication as ordered. 3) Increase fluid intake. Encourage patient to walk to increase peristaltic movement on the colon. Ancef Generic name: Cefazolin sodium Classification: Anti-infective, Cephalosporin, first generation Uses: Infection of the urinary tract, biliary tract, respiratory tract, bones ,joints, soft tissue and skin. prophylaxis in surgery. Side effects: extreme confusion, tonic clonic- seizures, mild hemiparesis Contraindications: Hypersensitivity to cephalosporins or related anti-biotics. Client/family teaching: 1) Immediately report any abnormal bleeding or bruising. 2) Oral meds should be taken on an empty stomach but if GI upset occurs, may be administered with meals. 3) Report any symptoms that may necessitate drug withdrawal such as vaginal itching or drainage, fever or diarrhea.

Morphine Sulfate Brand name: Duramorph, Statex, epimorph Generic name: Morphine sulfate Indications and dosages: Adult PO 10-30 mg q4h prn/ subcu:5- 15 mg prn, IV: 4-10 mg q4h prn. Classification: Narcotic

Uses: decreases severe pain Adverse/Side effects: Anorexia, nausea and vomiting, constipation, drowsiness, dizziness, sedation, confusion, urinary retention, rash, flushing, bradycardia. Pruritis. Drug Interaction: Increase effect with alcohol, sedatives-hypnotics, antipsychotic drugs and muscle relaxant. Contraindications: Asthma with respiratory depression, increased intra cranial pressure and shock. Nursing Consideration/Teaching: 1) Encourage patient not to use alcohol or CNS depressants, respiratory depression can result. 2) Suggest non-pharmacologic measures to relieve pain as patient recuperates from surgery. Scenario 3: Mrs. Smith Mrs. Smith, 66 years old, is one week post abdominal hysterectomy. She has not been discharged because her incision dehisced and is now open 2cm. x 1cm. with a 2cm pocket, draining a moderate amount of yellow purulent discharge. Mrs. Smith states that she is concerned about her fluid intake and that her urine is foul smelling. Dr’s Orders: Change drsg., irrigate with N/S and pack with plain packing od/prn Prepare for discharge Tylenol #3, i –ii tabs q4h prn

Nursing diagnosis: 1) Infection related to surgical incision as evidenced by moderate amount of yellow purulent discharge. 2) Impaired Urinary elimination related to surgery as evidenced by foul smelling urine. 3) Risk for dehydration related to anxiety as evidenced by patient states that she is concerned about her fluid intake and foul smelling urine. Nursing Intervention: 1) Encourage patient to increase protein intake to facilitate wound healing. 2) Measure intake and output. Encourage patient to drink plenty of fluids. 3) Assess patient’s skin turgor to determine dehydration.

Brand/Trade Name: Tylenol Acetaminophen Drug Classification: Analgesic Drug Action/effect: May block pain impulses peripherally that occurs in response to inhibition or prostaglandin synthesis; does not possess anti-inflammatory properties; antipyretic action results from inhibition of prostaglandins in the CNS (hypothalamic heat-regulating center); decreased pain, fever. Safe Dosage and route: •

Adult and child > 10 yr. PO 325-650 mg q4h prn, not to exceed 4g/day; REC 325650 mg q4h prn, not to exceed 4g/day.

•

Administer to patient crushed or whole; chewable tabs may be chewed.

•

Give with food or milk to decrease gastric symptoms; give 30 mins. Before or 2 hr after meals, absoption may be slowed.

Side effects/Adverse effects: • • • • • •

CNS: Stimulation, drowsiness GI: Nausea, vomiting, abdominal pain, hepatotoxicity HEMA: Leukopenia, neutropenia, hemolytic anemia, thrombocytopenia INTEG: rash, urticaria, angioedema SYST: Anaphylaxis TOXICITY: Cyanosis, anemia, jaundice, CNS stimulation, delirium followed by vascular collapse, convulsions, coma, death

Contraindications: Hypersensivity, intolerance to tartrazine (yellow dye no. 5), alcohol, table sugar, saccharin. Precautions: Anemia, hepatic disease, renal disease, chronic alcoholism, pregnancy

Nursing considerations/client teaching: Assessment: • • • • • • • • •

Monitor liver function studies: AST, ALT bilirubin, creatinine before therapy if long-term therapy is anticipated. Monitor renal function studies: BUN, urine creatinine, occult blood, albumin indicates nephritis. Monitor blood studies: CBC, pro-time if patient is on long-term therapy. Check I&O ratio, decreasing output may indicate renal failure Assess for fever and pain, type of pain, location, intensity, duration, temperature, diaphoresis. Assess mucosa, fingernail, beds for cyanosis, inquire about dyspnea, vertigo, headache, weakness Assess for chronic poisoning: rapid, weak pulse, dyspnea, cold clammy extremities; report immediately. Assess hepatotoxicity: dark urine, clay-colored stools, yellowing of skin and sclera; itching, abdominal pain, fever, diarrhea if patient is on long term therapy. Assess allergic reaction: rash, urticaria, if these occur, drug may have to be discontinued.

Pregnancy risk category: Patient education: •

Teach patient not to exceed recommended dosage, acute poisoning with lever damage may result; acute toxicity includes symptoms of nausea, vomiting, and abdominal pain

•

Tell patient to read label on other OTC drugs; many contain acetaminophen and may cause toxicity if taken concurrently.

•

Teach patient to recognize signs of chronic overdose; bleeding, bruising, malaise, fever, sore throat.

•

Inform patient that urine may become dark brown as a result of phenacetin (metabolite of acetaminophen).

•

Tell patient to notify prescriber for pain or fever lasting over 3 days.

Scenario 4: Jason Brown

Jason Brown is a 21 year old college football player. It is the first post-op day following surgery of a fracture of his right tibia and fibula. He has sutures over the anterior knee and the lateral malleolus and a posterior splint on the right leg. He reports considerable pain. He has an IV of N/S infusing TKVO. O2 is @ 2L./min via nasal prongs. DR’s Orders: VS q4h IV N/S TKVO C&S swab knee site Change drsgs. on sutures daily Morphine 5-10mg IM/IV q4h – prn for pain Senekot S i-ii tabs OD

Nursing diagnosis: 1) Acute pain related to fractured right tibia and fibula as evidenced by patient’s complain of considerable pain. 2) Risk for infection related to surgical incision on right anterior knee as evidenced by doctor’s order of culture and sensitivity swab on the knee site. 3) Risk for constipation related to Morphine as evidenced by Doctor’s order of Senekot.

Nursing Intervention: 1) Administer pain medication as ordered. 2) Monitor Vital signs. Change dressings as ordered. 3) Encourage patient to drink plenty of fluids and increase fiber on diet. Administer senekot as ordered. Morphine Sulfate Brand name: Duramorph, Statex, epimorph Generic name: Morphine sulfate Indications and dosages: Adult PO 10-30 mg q4h prn/ subcu:5- 15 mg prn, IV: 4-10 mg q4h prn. Classification: Narcotic Uses: decreases severe pain Adverse/Side effects: Anorexia, nausea and vomiting, constipation, drowsiness, dizziness, sedation, confusion, urinary retention, rash, flushing, bradycardia. Pruritis. Drug Interaction: Increase effect with alcohol, sedatives-hypnotics, antipsychotic drugs and muscle relaxant. Contraindications: Asthma with respiratory depression, increased intra cranial pressure and shock. Nursing Consideration/Teaching:

3) Encourage patient not to use alcohol or CNS depressants, respiratory depression can result. 4) Suggest non-pharmacologic measures to relieve pain as patient recuperates from surgery.

Senekot Generic name: Docusate sodium Pregnancy category: C Classification: Laxative, Emolient Action: Acts by lowering the surface tension of the feces and promoting penetration by water and fat, thus increasing the softness of the fecal mass Uses: To lessen strain of defecation in persons with hernia or CV disease or other diseases in which straining at stool should be avoided. Contraindications: Nausea, vomiting, abdominal pain, and intestinal obstruction. Drug Interaction: Docusate may increase absorption of mineral oil from the GI tract. Side effects: Excess activity of the colon resulting in nausea, diarrhea, or vomiting. Obstruction in the esophagus, stomach, small intestine or rectum. Client/Family Teaching: 1) May administer PO solutions of docusate with milk or fruit juices to help mask bitter taste. 2) Drink a glass of water with each PO dose. 3) When used in enemas, add 50- 100 mg to a retention or flushing enema. 4) Because docusate salts are minimally absorbed, it may require 1- 3 days to soften fecal matter.