Scenario 3

Alfred Angeles Final Case scenario # 3 2006 December 19 PRNR 198 Final Case scenario # 3 You are assigned to Mrs. Demajie, age 73 who has a history of hypertension. Two weeks ago she had a right CVA that has left her without a gag reflex. She has gastrointestinal feeding tube in place. When you make initial rounds, Mrs. Demajie’s tube feed is running and she is crying and moaning. You need to administer her 0800 hr medications. Doctors’ orders: Jevity plus 250 mL tid with 50 mL flush Herparin 5,000 units SC bid Furosemide 20 mg via GI tube 1 tab bid Nursing diagnosis 1. Acute pain related to tube feeding as evidenced by crying moaning 2. Self care deficit related to left sided CVA as evidenced by limited movement on left side ( Dx. Left sided CVA) 3. Potential Impaired skin Integrity related to left sided CVA as evidenced by limited mobility and dressing on GI feeding tube site. Nursing Interventions. 1. Administer medication as ordered stop tube feeding and put client on high Fowler’s position and assesses tube placement. 2. Perform simple exercises to regain energy. 3. Reposition the patient every 4 hrs. Brand name: Heparin Generic name: Heparin calcium Classification: Anti-coagulant Pregnancy category: C Action: Drugs that influence blood coagulation. Anti-coagulants do not dissolve previously formed clots but they do forestall their enlargement and prevent new clots from forming. Uses: Venous thrombosis, pulmonary embolism, acute coronary occlusions with MI’s and strokes cause by emboli or cerebral thrombi. Heparin is often use concurrently during the therapeutic initiation period. Adverse effects: GI: drug- induced hepatitis Derm: Alopecia (long term use) rashes, urticaria Hemat: anemia, thrombocytopenia Misc: fever and hypersensitivity Side Effects:

CV. hemorrhage ranging from minor local ecchymoses to major hemorrhagic complications from any organ or tissue. Dosage: Adjusted for each client and the basis of laboratory tests. Initial dose. 10000-20000 units. Drug Interactions Risk of bleeding may be increased if taken it with aspirin, NSAIDs, dipyridamole clopidrogrel. Heparins effect the prothrombin time used in assessin the response to warfarin. Digoxin, tetracyclines, nicotine and antihistaminesmay b\decreases the anticoagulant effect of heparin. Contraindications Hypersensitivity, uncrontrolled bleeding, severe thrombocytopenia, products contain benzyl alcohol should not be use in premature infants. Use cautiously with liver or kidney diseases. Nursing Consideration/ Teaching Assess for sign of bleeding and hemorrhage Observe injections sites for hematomas, ecchymosis or inflammation Activated partial thromboplastin time (aPTT) and hematocrit should be monitored prior and during the course of treatment Monitor platelet count q 2-3 days. Brand name: Laxix, furoside Generic name: Furosemide Classification: Loop diuretic Pregnancy Category: C Action: Inhibits the reabsorption of sodium and chloride in the proximal and distal tubules as well as ascending loop of Henle, this results in the excretion of sodium, chloride and to a lesser degree, potassium and bicarbonate ions. Uses: Edema associated with CHF, Nephrotic syndrome, hepatic cirrhosis, and a ascites Contraindication: Never use with ethacrynic acid Special concerns: Use with caution in premature infants due to prolonged half life in these clients. Side effects: fluid and electrolyte depletion leading to dehydration, hypovolemia, hypokalemia Vertigo, headache and dizziness. Dosage: 20-80mg/day as a single dose Nursing considerations 1. Clients resistant to one type of thiazide may respond to one another. 2. Liquid potassium preparations are bitter. When used, administer with fruit juice or milk to make them more palatable. 3. To prevent excess hypotension, reduce the dose of other anti hypertensive agents.