Scenario 3 Nursing Lab 3

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.

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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.

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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

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

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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.