Dave Jay S. Manriquez

INTEGRATED NURSING PRACTICE LEVEL 2/ ACCESS (LAB INTEGRATION ASSESSMENT)

Scenario 1

Gary DavisAge: 78 years oldRace: Caucasian

Admitting Diagnosis:Right Sided Congestive Heart Failure(Congestive Heart Failure)

- Also known as Heart Failure (HF)- Heart muscle weakness due to narrowing and constriction of blood vessel which resulted to

poor functioning valves causing dilation of heart chambers and resulted to decreased contractility and increase workload of the heart. Congestion usually develops because the heart is unable to move blood as quickly as possible as it should to meet the tissue requirements for oxygen.Etiology : Atherosclerosis and Hypertension (HPN) is a major contributing factor, risk of HF increases progressively with the severity of HPNDM predisposes an individual to HF regardless of the presence of concomitant CAD or HPNOther risk factors – cigarette smoking, obesity and high serum cholesterol

- May be caused by any interference with the normal mechanisms regulating cardiac output (CO)- CO depends on 1. Preload, 2. Afterload, 3. Myocardial contractility,

4. Heart rate, 5. metabolic state of the individualAny alteration in these factors can result to manifestations of HF.Left Sided Heart Failure – most common form of initial heart failure;

Results from left ventricular dysfunction, which causes blood to back up through the L atrium and into the pulmonary veins, manifested as pulmonary congestion and edema

Right Sided Heart Failure – causes backward blood flow to the R atrium and venous circulation. Venous congestion in the systemic circulation results in peripheral edema, hepatomegaly, splenomegaly, ascites and jugular venous distention.

- Clinical Manifestations = depend on age, underlying type and extent of heart disease and which ventricle is failing to pump effectivelyFatigue, Dyspnea, Tachycardia, Edema, Nocturia, Skin changes, Behavioral Changes, Chest Pain, Weight Changes

- Treatment : 1. Diuretics2. Angiotensin-Converting Enzyme Inhibitors

3. B-Adrenergic Blockers4. Inotropic Drugs - drugs that affect the strength of contraction of heart muscle (myocardial

contractility).- Sympathomimetic Drugs – dopamine, dobutamine, epinephrine and norepinephrine- Phosphodiesterase Inhibitors – Milrinone- Digitalis Preparations – digoxin (Lanoxin)

- Vasodilator drugs d.1 Nitratesd.2 Sodium Nitroprusside

Right Sided CHF S&S Left Sided CHF S&SDependent Edema RestlessnessAscites ConfusionDistended Jugular Veins Pulmonary CongestionWeight Gain FatigueIncrease Peripheral Venous Pressure Dyspnea

History:Angina

- Commonly known as angina- Sensation of chest pain, pressure or squeezing, due to partial occlusion or narrowing of the

coronary artery impeding the blood flow and causing ischemia of tissues and myocardium. Main cause is coronary artery disease which is an atherosclerotic process affecting the arteries feeding the heart.

- From Latin word angere “to strangle” and pectus “chest”- Classification :

a. Stable angina – effort angina, classic type, angina related to myocardial ischemia, precipitated by some activity and usually relieved by rest or after administration of nitroglycerin SL

b. Unstable angina – “crescendo angina”, a form of acute coronary syndrome, angina pectoris that worsens

Occurs at rest or even with minimal exertion. It is severe and of new onset. Occurs with a crescendo pattern (more severe, prolonged, frequent). May be a serious indicator of impending heart attack

- Signs and Symptoms = chest discomfort described as pressure, heaviness, tightness, squeezing, burning, or choking sensation

- Risk factors = smoking, diabetes, high cholesterol, high BP, sedentary lifestyle, family history of heart disease

- Treatment (patient): ASA, Antihypertensive, Anticoagulants, Cardiac Bypass Nitroglycerin transdermal patch

Coronary Artery Disease- A disorder of the heart’s blood vessels.

- A disorder of any of the major blood vessels that bring oxygen to the heart.- Reduced flow of oxygen and nutrients to the myocardium.

Avoidable Risk Factors Unavoidable Risk FactorsObesity Age >45 yearsSmoking Men and postmenopausal womenHigh fat/cholesterol/sodium Race (African decent)Diabetes (type 2) Family historyChronic Issues Congenital heart diseaseType A personality

Peripheral Vascular Disease- Refers to any disease or disorder of the circulatory system outside of the brain and heart.- Includes arterial, venous, and lymphatic. Problem with blood flow through peripheral vessel.

Caused by narrowing brought by atherosclerosis. May have partial or complete occlusion.- Most common cause is peripheral artery disease- Other causes = blood clot, diabetes, inflammation of the arteries, infection, structural defects,

blood vessel injury- Risk factors = positive family history of premature heart attacks or strokes,

>50 yo, overweight/obesity, sedentary lifestyle, smoking, DM, High BP, high cholesterol

- Symptoms of Peripheral artery disease depends upon the location and the extent of the blocked arteries

- Intermittent claudication manifested by calf pain usually while walking and dissipates at rest is the most common symptom of peripheral artery disease

- Complications = ulcers, gangrene, amputation- Treatment = angioplasty, medications, surgery, supervised exercises, lifestyle changes

Arterial PVD Venous PVDPalpable Pulses No YesTemperature Cool WarmEdema No edema/little EdemaHair No hair With hairCharacteristics Pale skin/dry/shiny Pinky redNails Thick toe nails/brittle/yellow NormalWound Type Round wound/ painful Irregular/ large/ lots of

exudates(serous)/ slightly painful

Significant Intermittent Claudication Need compression to heal/ Hemosedrin staining -> brown stains

Current Condition:

Fatigued – cause by the heart failureGreenish Productive Cough – cause by the heart failure, pulmonary congestion

Dyspnea on exertion – cause by the heart failure or myocardial ischemiaBilateral pitting edema to legs – cause by the heart failure, right sided – venous congestionVenous stasis ulcer on his right inner ankle – not healing due to venous congestion, need compression to heal

Initial Assessment:Moderate chest pain – cause by angina

Regular Medication:Digoxin (Lanoxin) 0.25 mg OD

Indication: Heart failure. AntiarrythmicsAction: Increases the force of myocardial contraction. Increased cardiac output (positive inotropic effect) and slowing of the heart rate (negative chronotropic effect).Metabolism: KidneyHalf-life: 36-48 hrsN. Dose: 0.125-0.5 mgAdverse/ S/E: fatigue, bradycardia, and nausea and vomitingNursing Cons: Monitor apical pulse for 1 full min before administration. Withhold dose and notify health care professional if pulse rate is <60 bpm in an adult.

Digitalis toxicity can be caused by high levels of digitalis in the body. Many diuretics can cause potassium loss. Low levels of potassium in the body increase the risk of digitalis toxicity. Digitalis toxicity may also result in persons who take the drug and who have low levels of magnesium in the body.Signs of Digitalis toxicity: confusion, irregular pulse, loss of appetite, nausea and vomiting, diarrhea, palpitations, visual change

Lasix (Furosemide) 40 mg ODLasix (Loop Diuretic)Indication: Edema due to heart failure, hepatic impairement or renal dse. HypertensionAction: Inhibits reabsorption of sodium and chloride from loop of Henle. Increase renal excretion of H2O, Na, Cl, Mg, K and Ca. Diuresis (excess fluid edema, pleural effusions). Decrease BPMetabolism: LiverHalf-life: 30-60 minsN. Dose: 20-80 mgContraindicated: HypersensitivityS/E: headache, hypotension, dehydration

Nursing Cons: Monitor BP and pulse, watch for falls, assess fluid status.

Nitroglycerin patch (Nitro-Dur) patch 0.4 mg on in the am off in the pmIndication: Anti-anginals, mgt of angina pectoris.Action: Increases coronary blood flow by dilating coronary arteries and improving improving collateral flow to ischemic regions. Relief from angina attack. Increased cardiac output, reduction of BP.Metabolism: LiverHalf-life: 1-4 min

N. Dose: 0.2-0.4 mg/hrContraindicated: hypersensitivityS/E: dizziness, headache, hypotensionNursing Cons: Assess pain, monitor BP and pulse

Standing order Oxygen at 3L/min via nasal prongs prn – to have relief in breathing difficultyDaily fluid restriction of 2L – to prevent hypertension, especially client has heart failure

Lab results: WBC 24 X 10*9/L – increase due to the venous woundRBC 4 X 10*12/L – decrease production brought about by the decrease hemoglobin cause by the heart failureHGB 125 g/L - protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues and returns carbon dioxide from the tissues back to the lungs, decrease due to poor blood circulation cause by heart failureNeutrophils 14 X 10*9/L – type of white blood cells, are recruited to the site of injury within minutes following trauma, and are the hallmark of acute inflammation, increase due to the venous woundSodium 128 mmol/L – decrease due to the loop diureticChloride 96 mmol/L - decrease due to the loop diureticPotassium 2.9 mmol/L - decrease due to the loop diuretic

Normal Value Range Why it is ordered?WBC 5-10 X 10*9/L Routine assessment; infection;

inflammation; blood or bone marrow disorders

RBC 4.7-5.14 X 10*12/L Suspected anemia; polycythemia; routine

HGB 140 g/L to 180 g/L Suspected anemia; polycythemia; routine

Neutrophils 2.0-7.0 X 10*9/L To detect specific infections/disorders

Sodium 135-145 mmol/L Electrolyte imbalance; edema or dehydration

Chloride 98-106 mmol/L Electrolyte imbalance; acid-base balance

Potassium 3.5-5.0 mmol/L Arrhythmia; hypertension; kidney dse; electrolyte imbalance

Nurse Practitioner Order:Nitroglycerin Spray 0.4mg S.L. STAT, may repeat q 5 minutes for a maximum of 3 doses

Indication: Anti-anginals, mgt of angina pectoris.

Action: Increases coronary blood flow by dilating coronary arteries and improving improving collateral flow to ischemic regions. Relief from angina attack. Increased cardiac output, reduction of BP.Metabolism: LiverHalf-life: 1-4 minN. Dose: 400 mcg/spray or 0.4mg/sprayContraindicated: hypersensitivityS/E: dizziness, headache, hypotensionNursing Cons: Assess pain, monitor BP and pulse

Ciprofloxacin 500mg OD Indication: treatment of the ff. bacterial infection. (Fluoroquinolones) Action: Death of susceptible bacteria. Anti-infectives Metabolism: Liver, excrete thru kidney Contraindicated: hypersensitivity N. Dose: 500mg-700mg q12 hrs S/E: dizziness, headache, insomnia, diarrhea, nausea Nursing Cons: Assess for infection (v/s, appearance of wound, sputum, urine and stool, WBC, Urinalysis, frequency and urgency of urination.)

Potassium Chloride 20 mEq PO BIDIndication: PO/IV: Treatment of potassium depletion. Arrythmias due to digoxin toxicity.Action: Prevention of deficiency.Metabolism: excretion on kidneyN. Dose: 20-40 mEq/dayContraindicated: Hyperkalemia, severe renal impairmentS/E: adb pain, diarrhea, flatulence, nausea and vomitingNursing Cons: Monitor pulse and BP. Assess for sign and symptoms of hypokalemia such as weakness and fatigue

Sputum C&S – because of the production of greenish sputum. For Isolation just mention to wear PPE such as: gown, gloves, mask, eyewearCheck electrolytes in 30 days

The family calls to inquire: Gary’s Condition

PLAN OF CARESCENARIO 1

1. Verbalize knowledge with the instructor.2. Wash hands.3. Enter the room, check for safety (bed down, side rails up, call bell within reach, bed brakes on,

no clutters around). Ensure Privacy.4. Introduce yourself .

5. QPA- General appearance (Client is in supine position, awake and alert)- Airway is open- With difficulty of breathing- Raise the head of the bed, high fowler’s position- Put Oxygen Saturation. Administer Oxygen at 3 L/min via nasal prongs6. Chest pain assessment (PQRST).- P: What events or activities precipitated the pain?- Q: What does the pain feel like? (pressure, dull, aching, tight, squeezing)- R: Where is the pain located? Does the pain radiate to other areas?- S: Pain scale out of 10- T: When did the pain begin? Has the pain changed since this time? Have you had pain like this

before?7. Vital signs (BP (put a pillow below the arm), apical pulse rate, respiration (rate, rhythm, depth)).8. SBAR with the doctor. Clarify to nurse practitioner to continue giving the patch on.9. Wash hands. Gather supplies. Do Preliminary check on meds within MAR, Physician’s order.10. Do two checks first then the third check at the bedside. Locked the medication cart.- Possible STAT med: Nitroglycerin Spray 0.4mg SL STAT, may repeat q 5 minutes for a maximum

of 3 doses11. Go to patient room; check two identifiers, do the third check of med at bedside, educate the

client about the med. Ask patient if he have taken the medication before.12. Prime the Nitroglycerine Spray before giving. Administer STAT medication as ordered.13. Inform client that he will be reassessed after 5 minutes and be given with another dose as

prescribed (if necessary)14. Continue QPA (starting circulation)- Repeat V/S, this time include the temperature- Color and texture of the skin- Cap refill both upper and lower extremities15. LOC16. LOO – person, place, and time17. Input (oxygen at 3L/min) and Output (venous ulcer – intact and dry)18. Pain Assessment (PQRST) – should be already done19. Focus assessment- Chest assessment- Peripheral Vascular Assessment (edema, DVT, palpable pulses, color, warmth, moisture,

swelling)20. Do health teaching on the client.21. Check for safety.22. If patient become stable, inform him that you will be going out of the room, but will be checking

on him anytime, call bell place near patient.23. Transcribe the Stat order. Process the Doctor’s order, sign the MAR, sign the STAT order in the

physician’s order with red pen including time when given.24. Answer call from the family. And relay the current condition of the patient to the family.

SBAR

Good morning Maria. My name is Dave Manriquez, I’m LPN student of Vancouver Community College. I am calling regarding your client Gary Davis about a change in his status I have noticed this morning? Do you have few minutes to discuss about it?

His background information is that he is admitted for having right-sided congestive heart failure. He has a history of having Angina, Coronary Artery Disease, and Peripheral Vascular Disease. He has a bilateral pitting edema and venous stasis ulcer on his right inner ankle. Mr. Davis receives Oxygen therapy at 3 L/min via nasal prongs as needed and his fluid intake is restricted to 2L of water per day. His current medication consisting of Digoxin 0.25mg PO once daily, Lasix 40mg once daily and he has a Nitro Patch 0.4mg which is put on in the morning and remove in the evening. During assessment I noticed that Gary Davis seems to be fatigued and he has productive cough and dyspnea on exertion. This morning he states that he is experiencing moderate chest pain. I would like to recommend antianginal medication to relieve his chest pain.

Possible Doctor’s order:Please give Nitroglycerin Spray 0.4mg SL STAT, may repeat q 5 minutes for a maximum of 3 doses. If not relieve after three doses, please send to ER.

May I repeat your order Doctor?Are you coming here later to check on the patient? Thank You.

Health Teachings: Scenario 1 (Gary Davis)

1. Informed patient to ask help immediately if experiencing any chest pain that is radiating and also ask for help if experiencing difficulty in breathing.

2. Informed patient to always elevate the head part of the bed or use pillows to elevate the head to facilitate proper breathing.

3. Informed patient the proper technique in breathing, breath from the diaphragm: inhale for 6 secs, hold it for 2 secs, and exhale slowly for 7 secs. This is to prevent the use of accessory muscle that make it stiffens that will result in breathing difficulty. This is done only if patient can tolerate it.

4. Caring for venous stasis ulcer.- Make sure the wound is clean and dry always- Report to physician or to a clinic if there is wound infection- Informed patient to elevate legs while resting using a pillow- Informed patient to wear TED stockings in the morning

5. Diet and Exercise- Informed patient do this exercise that are not stressful but just enough to make him active- Informed patient to eat high fiber foods, less calories, sodium and fats- Informed patient to increase fluid intake but within the limit prescribed by the physician- Informed patient to always adhere to the diet prepared by a nutritionist if having one

6. Informed patient about the side effects of the medication he is on. Informed him about hypotension that may make him dizzy that might cause him to fall.

Scenario 2

Randeep SandhuAge: 88 years oldRace: Indo-Canadian heritage

Recent Condition:Labile blood pressure - or borderline hypertension, is a term used to describe blood pressure measures that may fluctuate abruptly and repeatedly from normal to high.Types of Hypertension:

a. Essential or primary hypertension – 95% of the people having hypertension, the cause is unknown.

b. Secondary hypertension – there is a cause, may come from the condition affecting the artery, chronic disease such as DM. Lifestyle can also affect such as smoking and being obese.

c. Isolated systolic hypertension – the rise of systolic and diastolic pressure.d. Malignant hypertension – when blood pressure rises extremely quick, diastolic pressure may

rise to 130.e. Benign hypertension – is an essential hypertension, running for a considerably long period of

time and being asymptomatic.f. Resistant hypertension – even with medication the condition is not cured.

Sign and symptoms of Hypertension Sign and symptoms of HypotensionNumbness in the arm and legsBlurred visionConfusionChest PainHeadacheRestless

FatigueDizziness/light-headednessNauseaClammy skinLoss of consciousnessBlurry vision

G-tube in situ for intermittent enteral feeding and medication administration - A gastrostomy tube allows the delivery of supplemental nutrition and medications directly into the stomach. It also provides a mechanism to drain gastric contents if required.In situ – in placedIntermittent – not constant

Arterial ulcer on his right leg - The ulcer has punched-out appearance. It is intensely painful. It has gray or yellow fibrotic base and undermining skin margins. Pulses are not palpable. Associated skin changes may be observed, such as thin shiny skin and absence of hair. They are most common on distal ends of limbs.

Arterial PVD Venous PVDPalpable Pulses No YesTemperature Cool WarmEdema No edema/little Edema

Hair No hair With hairCharacteristics Pale skin/dry/shiny Pinky redNails Thick toe nails/brittle/yellow NormalWound Type Round wound/ painful Irregular/ large/ lots of

exudates(serous)/ slightly painful

Significant Intermittent Claudication Need compression to heal/ Hemosedrin staining -> brown stains

Restless throughout the night – sign of hypertensionLast blood pressure at 0645 is 250/110 and remain restless (a call has been placed out to the doctor but has not called back yet) – sign of hypertension increase blood pressure

History:Left Cerebrovascular Accident with dysphagia

A cerebrovascular accident is the medical term for a stroke. A stroke is when blood flow to a part of your brain is stopped either by a blockage or a rupture of a blood vessel. The more quickly you get treatment, the better the prognosis. When a stroke goes untreated for too long, there can be permanent brain damage.

There are two main types of cerebrovascular accident, or stroke. An ischemic stroke is caused by a blockage, and a hemorrhagic stroke is caused by a breakage in a blood vessel. In both cases, part of the brain is deprived of blood and oxygen, causing the brain’s cells to die.

Ischemic Stroke

An ischemic stroke occurs when a blood clot blocks a blood vessel, preventing blood and oxygen from getting to a part of the brain. There are two ways that this can happen. When a clot forms somewhere else in your body and gets lodged in a brain blood vessel, it is called an embolic stroke. When the clot forms in the brain blood vessel, it is called a thrombotic stroke.

Hemorrhagic Stroke

A hemorrhagic stroke occurs when a blood vessel ruptures, or hemorrhages, which then prevents blood from getting to part of the brain. The hemorrhage may occur in a blood vessel in the brain, or in the membrane that surrounds the brain.

Symptoms of a Cerebrovascular Accident

difficulty walking

dizziness

loss of balance and coordination

difficulty speaking or understanding others who are speaking

numbness or paralysis in the face, leg, or arm, most likely on just one side of the body

blurred or darkened vision

a sudden headache, especially when accompanied by nausea, vomiting, or dizziness

Stroke affected the left side of your brain, you will have problems with the right side of your body.

The left side of the brain controls the ability to speak and understand language in most people.

The right side of the brain controls the ability to pay attention, recognize things you see, hear or

touch, and be aware of your own body.

You may have problems with left-sided CVA:

speaking

listening

reading

writing

dealing with numbers

understanding speech

thinking of words when talking or writing

Swallowing musculature is asymmetrically represented in both motor cortices. Stroke affecting the hemisphere with the dominant swallowing projection results in dysphagia and clinical recovery has been correlated with compensatory changes in the previously non dominant, unaffected hemisphere. This ‐asymmetric bilaterality may explain why up to half of stroke patients are dysphagic and why many will regain a safe swallow over a comparatively short period. Despite this propensity for recovery, dysphagia carries a sevenfold increased risk of aspiration pneumonia and is an independent predictor of mortality.

Baseline data in Kardex:Blood pressure is 138/84

Regular Medications Include:Ramipril (Altace) 2.5mg via G-tubeClopidogrel (Plavix) 75mg OD via G-tubeIndication: Antiplatelet agentsAction: Inhibits platelet aggregation by irreversibly inhibiting the binding of ATP to platelet receptors. Decreased occurrence of atherosclerotic events in patients at risk.Metabolism: LiverHalf-life: 6 hrsContraindication: hypersensitivityS/E: GI bleeding, rash, fatigue, headacheNormal Dose: 75mg once dailyNursing Cons: Take medication as directed. Monitor for signs of bleeding.

ASA (Aspirin) 81mg OD via G-tubeSalicylatesIndication: Antipyretic, Non-opioid analgesic. Mild to moderate pain. Prophylaxis of transient ischemic attack and MI.Action: Analgesia, reduce inflammation, reduction of fever, decrease incidence of TIA and MI.Metabolism: Liver, excreted in kidneyHalf-life: 2-3 hrsNormal Dose: 50-325mg once dailyContraindication: hypersensitivityS/E: GI bleeding, abdominal painNursing Cons: Monitor for any signs of bleeding.

Lab Results:Cholesterol 7.5 mmol/L – causes hypertension, may cause plaque formationWBC 4 X 10*9/L – patient has arterial insufficiency, may also cause white blood cells (leukocytes) to accumulate in small blood vessels, Buildup of white blood cells in small blood vessels may also plug the vessels, further contributing to ischemia might affect the number of the WBCHGB 90 X 10*9/L – decrease due to hypertension that disrupt the normal flow of the blood in the circulatory system, lesser red blood cells got oxygenatedLDL 4.5 mmol/L – causes hypertensionHDL 0.75 mmol/L – causes hypertension

Normal Value Range Why it is ordered?Cholesterol <5.2 mmol/L Risk for cardiac diseaseWBC 5-10 X 10*9/L Routine assessment; infection;

inflammation; blood or bone marrow disorders

HGB 140 g/L to 180 g/L Suspected anemia; polycythemia; routine

LDL <2.59 mmol/L Risk for cardiac diseaseHDL >1.0 mmol/L Risk for cardiac disease

Doctors call back with the following orders: Increase Ramipril (Altace) to 5mg via G-tube STAT and repeat B/P in 30 minutesIndication: HypertensionAction: ACE inhibitor; increase plasma renin levels and decrease aldosterone level. Lowering BP in hypertensive patients.Metabolize: liver, excrete thru urineHalf-life: 13-17 hoursNormal Dose: 2.5mg once daily for 1 wk, then 5mg once daily for 3 wksContraindicated: Hypersensitivity; history of angioedemaS/E: cough, hypotension, taste disturbance

Nursing Consideration: Monitor BP and pulse frequently. Assess signs of angioedema (dyspnea, facial swelling)

Metoprolol (Lopressor) 25 mg via G-tube STAT then ODIndication: Hypertension, Angina Pectoris, MIAction: Block stimulation of Beta1 (myocardial) adrenergic receptor. Decreased BP and heart rate. VasodilationMetabolism: LiverHalf-life: 3-7 hrsNormal Dose: 25-100mg per dayContraindicated: Uncompensated HF. Pulmonary edema, BradycardiaS/E: fatigue, weakness, erectile dysfunctionNursing Consideration: Monitor BP, ECG, and pulse frequently during dose adjustment

CBC - blood test used to evaluate your overall health and detect a wide range of disorders, including anemia, infection and leukemia.

PLAN OF CARE SCENARIO 2

1. Wash hands2. Enter patient room, introduce self to patient, check safety of the environment (no clutters

around, bed down, side rails up, call bell within reach of the patient, bed brakes on). Privacy.3. QPA (airway, breathing only)- General Appearance (patient awake, flat in bed, looks restless)- Airway (eg. patient talking)- Breathing (eg. ease in respiration, raise the head of the bed if needed)4. Take Vital Sign such as BP put pillow below arm, Apical pulse, RR (take note of the time)5. SBAR the doctor (take note of the time of conversation)6. Wash hands7. Prepare the STAT medication; Do preliminary check of the STAT med- Gather necessary supplies; Three checks and 7 rights- Crush tablet into fine powder and dissolve in 15-30 cc tepid water- Lock drug cart- Identify client 2 identifiers; Inform client about the medication and the procedure- Complete relevant assessment – do an abdominal assessment (inspect for any lesion;

auscultate for bowel sound; palpate for abd pain); check if G-tube is intact (the line should not be more than 2cm); check for the site of G-tube for any signs of infection, redness, irritationMake sure patient is in flat position and bent knees while doing the abdominal assessment.

- Place patient in semi-fowlers position at 45 degrees; place waterproof pad on abdomen- Don gloves- Check placement of tube according to facility policy; check for ph range it should be acidic

below 5

- Flush the G-tube with 30-50 cc of tap water. Inform patient it might cause a tingling sensation in the abdomen

- Ensure med suspended in the air by giving a stir and draw up dissolved meds into syringe- Unplug medication tubing and administer medication; follow with 30-60 cc water- Put patient in semi-fowlers position for the next 30 mins following administration- Remove gloves, wash hands, note the time med given8. Reassess BP after 30 minutes9. Continue QPA (starting with circulation)- Check capillary refill for both upper and lower extremities- Vital Signs include temperature this time- Skin tone, warm and dry- LOC- LOO (person, place, and time)- In and Out (wound intact and dry)- Ask for any pain- Focused assessment: Peripheral Vascular Assessment (color, warmth, movement, sensation,

palpable pulses, edema, DVT) and Transfer Assessment (bec patient has history of left CVA)10. Do health teaching to the client11. Post assessment (Vital signs)12. Check for safety13. Transcribe/Process Doctors Order. Do the proper documentation. FDAR charting.

SBAR

Good morning Doctor Lee. My name is Dave Manriquez, I’m LPN student of Vancouver Community College. I’m doing a call back for your client Randeep Sandhu about a change in his status. Do you know him? When I did my round this morning I found Mr. Sandhu being restless. I did take his BP and it is 250/110 at 0645.

I just want to share to you his background. He has a history of left CVA with dysphagia. He has a G-tube used for feeding and medication administration. He have regular medications of Ramipril 2.5mg via G-tube, Clopidogrel 75mg OD via G-tube, and ASA 81mg OD via G-tube. His PR 110 bpm, RR 18 cpm. Do you have any recommendation to treat the client?

Possible STAT order by the doctor:Increase Ramipril to 5mg via G-tube STAT and repeat B/P in 30 minutesMetoprolol 25mg via G-tube STAT then OD

Repeat what the doctor said. Are you coming later this afternoon to check on the patient?Thank You. Health Teachings: Scenario 2 (Randeep Sandhu)

1. Diet and Exercise

- Informed patient do this exercise that are not stressful but just enough to make him active- Informed patient to eat high fiber foods, less calories, sodium and fats- Informed patient to increase fluid intake- Informed patient to always adhere to the diet prepared by a nutritionist if having one2. Informed client to always let someone check his blood pressure.3. Informed patient to report any signs of hypertensive crisis such as headache, hot flushes, and

nosebleeds immediately to a health practitioner.4. Caring for arterial ulcer.- Make sure the wound is clean and dry always- Report to physician or to a clinic if there is wound infection- If given the chance, while in wheelchair/side of the bed to lower down the legs to promote

arterial circulation5. Caring for CVA.- Informed patient that he has right sided weakness that he cannot just move by his own that he

need assistance in mobility. Inform client that we are there to help them so that they will not be worried if they want to ambulate.

6. Informed patient about the side effects of the medication he is on. Informed him about hypotension that may make him dizzy that might cause him to fall.

Scenario 3

Paul GeorgeAge: 69 years oldRace: First Nations heritage

Diagnosis:

Type 2 Diabetes Mellitus

Adult onset >30 yrs old, non-insulin dependent, most prevalent type of DMChronic condition that affects body’s way of metabolizing glucoseBody either resists the effects of insulin or doesn’t produce enough insulin to maintain a normal blood glucose levelInsulin = a hormone that regulates the movement of sugar into cellsSymptoms = 3Ps - polyphagia, polydipsia, polyuria, Fatigue, frequent infections, areas of darkened skin, (armpits/neck) = acanthosis nigricans Risk factors = overweight, age (older), Race (Hispanics, Asian-Americans), Aboriginal peopleComplications = heart and blood vessel disease (angina, atherosclerosis)Nerve damage (neuropathy) – tingling, numbness, painKidney damage (nephropathy) Eye damage (diabetic retinopathy), glaucoma and cataract – leads to blindness Foot damage - nerve damage in the feet bec of poor blood flow to the feetTests = Fasting blood glucose = >=7mmol/L

Random blood glucose = >=11.1 mmol/L Two-hour OGTT = >=11.1 mmol/L HgbA1c = >=6.5%

Treatment = Insulin alone or in combination with oral hypoglycemic agent and lifestyle changes

Sign and symptoms of Hyperglycemia Sign and symptoms of HypoglycemiaHigh blood glucoseBlurred VisionDifficulty concentratingFrequent urinationHeadachesIncreased fatigue

ShakinessNervousness and anxietySweating, chills, and clamminessIrritability or impatienceConfusion including deliriumLight-headedness and dizziness

Peripheral Vascular Insufficiency - condition that occurs when the venous wall and/or valves in the leg veins are not working effectively, making it difficult for blood to return to the heart from the legs. Venous insufficiency occurs when these valves become damaged, allowing the blood to leak backward. Valve damage may occur as the result of aging, extended sitting or standing or a combination of aging

and reduced mobility. When the veins and valves are weakened to the point where it is difficult for the blood to flow up to the heart, blood pressure in the veins stays elevated for long periods of timeDiabetic vascular disease refers to the development of blockages in the arteries, sometimes called “hardening of the arteries”, throughout the body because of diabetes. May lead to the formation of diabetic ulcer.

History:Open wounds on his feet (hospitalized in the past for poor wound healing resulting in diabetic ulcers on his feet)

Recent Condition:Nausea (Paul administered extra regular insulin as he thought the nausea was caused by hyperglycemia)Decrease AppetiteDiabetic ulcer on his right great toe – cause by constant increase in blood sugar

Lifestyle:Difficulty managing dietary intake because of strong cravings for carbohydrates rich foods (resulted to hyperglycemia)

Regular Medication:Humulin R Insulin per sliding scale; following results of glucometer reading given 30 minutes ac breakfastIndication: Control hyperglycemia with patient having Diabetes MellitusAction: Lower blood glucose by stimulating glucose uptake in skeletal muscle and fat; inhibiting production in the liver.Contraindication: HypoglycemiaS/E: HypoglycemiaMetabolze: liver, spleen, kidney, and muscleOnset: 30-60 mins; Peak: 2-4 hrs; Duration: 4-8 hrsN. Dose: 0.5 – 1 unit/kg/dayNursing Implication: Assess patient for symptoms of hypoglycemia (anxiety; restlessness; tingling in hands, feet, lips, or tongue; chills; cold sweats; confusion; cool pale skin)

Humuin N Insulin 10 units 30 minutes ac breakfast and dinnerIndication: Antidiabetic. Control hyperglycemia in patients with type 1 and 2 DM.Action: Stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production. Control of hyperglycemia in diabetic patients.Metabolism: liver, spleen, kidney and muscleOnset: 2-4 hrs; Peak: 4-10 hrs; Duration: 10-18 hrsN. Dose: 0.5 – 1 unit/kg/dayContraindicated and Adverse effect: hypoglycemiaNursing Cons: Assess for signs of hypoglycemia

Dimenhydrinate (Gravol) 50mg PO/IM Q6H prn.Used: preventing and treating nausea and vomiting, dizziness caused by motion sickness. It is an antihistamine and anticholinergic. It works in the brain to decrease nausea and vomiting, and dizziness.N. Dose: 50mg – 100mg q 4-6 hrs; to a maximum of 400mg in 24 hrsContraindicated: taking MAO inhibitor (anti-depressants)Nursing Cons: may cause drowsiness, and dizziness: watch out for falls

Admission Order:Facility Diabetic Protocol and treatment for hypoglycemia

Capillary Blood Glucose Able to swallow NPO Decreased LOC2.2-3.9 mmol/L -Give 5 Dextrosol/Glucose

tablets or 1 tube of Insta-Glucose gel or 180ml of juice-Recheck blood glucose in 15 minutes-Repeat treatment and glucose checks q 15mins until blood glucose >4mmol/L-When blood glucose level >4 mmol/L, give snack as per policy or feed meal is less than 30mins away

-Obtain Glucagon from the emergency kit, prepare as per instruction on package – note expiration date. Repeat injection as per policy.-Call physician immediately. Repeat blood glucose q 15mins until >4 mmol/L-Continue to monitor blood sugar q 30 mins for the next 2hrs or until stable-Evaluate for need to transfer to ER

Obtain Glucagon from the emergency kit, prepare as per instruction on package – note expiration date. Repeat injection as per policy.-Call physician immediately. Repeat blood glucose q 15mins until >4 mmol/L-Continue to monitor blood sugar q 30 mins for the next 2hrs or until stable-Evaluate for need to transfer to ER

Below 2.2 mmol/L -Give 7 Dextrosol/Glucose tablets or 2 tubes of Insta-Glucose gel or 200ml of juice-Recheck blood glucose in 15 minutes-Repeat treatment and glucose checks q 15mins until blood glucose >4mmol/L-When blood glucose level >4 mmol/L, give snack as per policy or feed meal is less than 30mins away

-Treat as Above -Treat as Above

Don’t forget – adequate blood sample for accuracy, give follow up snack once blood glucose >4 mmol/L, recheck blood glucose, document treatment and outcome, reorder Diabetic Emergency Kit from pharmacy.

GlucagonIndication: Hormones. Acute management of severe hypoglycemia when administration of glucose is not feasible.Action: Stimulates hepatic production of glucose from glycogen stores (glycogenolysis). Increase in blood glucose.Metabolism: Liver, plasma, and kidneysHalf-life: 8-18 minsContraindicated: hypersensitivity

S/E: signs of hyperglycemiaNormal Dose: 4.4 mcg/kgNursing Cons: Watch for signs of hyperglycemia. Vital signs.

Labs Values:RBC 5.6 X 10*12/L - not so significant just a little above normalWBC 10 X 10*9/L - normalHemoglobin A1c 12.3% - its means the patient has a poor control with his diabetes, the patient might not complying with his medication or patient is still eating too much sweets Na+ 140 mmol/L - normalK+ 4.0 mmol/L – normal

Normal Range Value Why it is ordered?RBC 4.7-5.14 X 10*12/L Suspected anemia;

polycythemia; routineWBC 5-10 X 10*9/L Routine assessment; infection;

inflammation; blood or bone marrow disorders

HGB A1c 4.5-6 % To know the average blood glucose for the past 3 mons.

Sodium 135-145 mmol/L Electrolyte imbalance; edema or dehydration

Potassium 3.5-5.0 mmol/L Arrhythmia; hypertension; kidney dse; electrolyte imbalance

Doctor’s orders:Dietitian to reassess dietCall doctor if glucometer readings <3 or >20

Blood Glucose Humulin R (units) SC0-4 Diabetic protocol4.1-8 None8.1-10 210.1-12 412.1-14 614.1-16 816.1-18 1018.1-20 12>20 14 – Call MD

PLAN OF CARE SCENARIO 3

1. Wash hands

2. Enter patient room, introduce self to patient, check safety of the environment (no clutters around, bed down, side rails up, call bell within reach of the patient, bed brakes on)

3. QPA (airway, breathing)- General Appearance (patient awake, flat in bed, feels nauseated)- Airway (eg. patient talking)- Breathing (eg. ease in respiration, raise the head of the bed if needed)4. Check blood glucose (wear gloves). Depending on the result and the level of consciousness of

the patient do the appropriate diabetic protocol. Ask if the patient can swallow. Ask patient what sugar she prepare to have (eg. dextrose tablets, instaglucose gel, or juice)

- Remove gloves after taking blood glucose5. Gather supplies for hypoglycemic protocol6. Do preliminary check, three checks with the diabetic protoccol and 7 rights for the meds to be

given7. Locked the med cart8. Go inside the room; do 2 identifiers; educate client about the med and ask if he had taken the

med before9. Administer meds as per hypoglycemic protocol10. Check blood glucose after 15 minutes. Depending on the result, if blood sugar is still high ask

again the client for his preference of sugar.11. Apply the hypoglycemic protocol again if needed until blood glucose is stabilized =>4 mmol/L12. Reassess client for signs and symptoms of hypoglycemia13. Continue QPA- Vital signs: BP put pillow below arm; PR; RR, including temperature- Circulation (eg. cold clammy skin, diaphoretic signs of hypoglycemia)- Capillary refill test- LOC- LOO (person, place, time)- In and Output (diabetic ulcer on right leg intact and dry)- Pain Assessment- Focused Assessment: Peripheral Vascular Assessment (color, warmth, movement, sensation,

palpable pulse, edema, and DVT). Abdominal Assessment (inspect, auscultate, palpate)14. Provide health teaching to the client15. Check for safety (bed down, side rails up, bed brakes on, no clutters around)16. Handwashing17. Documentation: transcribe/process hypoglycemic protocol, sign MAR and diabetic record. FDAR

charting

Health Teachings: Scenario 3 (Paul George)

1. Diet and Exercise- Informed patient do this exercise that are not stressful but just enough to make him active- Informed patient to eat high fiber foods, less calories, sodium and fats- Informed patient to increase fluid intake- Informed patient to always adhere to the diet prepared by a nutritionist if having one

2. Informed patient to check first his blood glucose using a glucometer before injecting any insulin to prevent any hypoglycemic attack especially in this scenario that he has a regular insulin injection.

3. Informed patient to report any signs of hypoglycemia such as: clod clammy skin, diaphoretic, light headedness/dizziness, confusion immediately to a health practitioner.

4. Caring for diabetic wound.- Make sure the wound is clean and dry always- Report to physician or to a clinic if there is wound infection- Informed patient to wear proper footwear, something that has more space on it for the feet to

move around, not those shoes that is very tight- Informed patient to remove any clutters or things on the way that might cause harm to him

especially he has decrease sensation to his lower extremities due to diabetic neuropathy

Source for research: https://www.nlm.nih.gov/medlineplus/ency/article/000165.htmhttp://www.allinahealth.org/http://www.everydayhealth.com/hypertension/understanding/types-of-hypertension.aspxhttp://my.clevelandclinic.org/services/heart/disorders/hvi_chronic_venous_insufficiency

Scenario No. 1 Gary DavisDate/Time Focus Discipline Data Action Response12/03/151045

Pain

Reassessment of Pain

D – At 1021 received patient in supine position, dyspneic, and complained of chest pain, he verbalized squeezing pain, not radiating, severity is 7/10 and started this morning. V/S: BP 140/90 mmHg; apical pulse 105 bpm; RR 25 cpm. A – Raised head of the bed. Oxygen Sat taken 85% at RA, oxygen given at 3L/min via nasal prong. At 1030 STAT medication given Nitroglycerin Spray 0.4mg administered. R – At 1035 client verbalized decrease pain from 7/10 to 5/10. ---------------------------------------------------D - At 1035 pain 5/10; BP 130/86 mmHg; Apical pulse 100 bpm. A – At 1037 another dose of Nitroglycerin spray 0.4mg SL administered. R- At 1042 denied pain and easily breathing. ------------------------------------------djsm VCCSPN

Senario No. 2 Randeep SandhuDate/Time Focus Discipline Data Action Response12/03/150800

Blood Pressure Monitoring

D – At 0700 client is seen on bed, awake, and conscious, oriented x3, appears restless. V/S: BP 250/110 mmHg; PR 100 bpm; RR 24 cpm. A – Notified the physician. At 0710 administered Ramipril 5mg amd Metropolol 25mg via G-tube STAT. R – At 0740 BP 130/80. ----------djsm VCCSPN

Scenario No. 3 Paul GeorgeDate/Time Focus Discipline Data Action Response12/03/151110

Blood Glucose Monitoring

Reassessment

D – Received patient in supine position, looks weak, diaphoretic, verbalize feeling of dizziness. A – At 1010 blood glucose checked 2.8 mmol/L. At 1015 Instagel 1 tube given as per diabetic protocol. -------------------------A – At 1030 blood glucose rechecked 3.6 mmol/L. At 1033 180cc of apple juice was given. R – At 1048 blood glucose reading is 4 mmol/L. Patient verbalized not feeling dizzy anymore. --------------------------------------------djsm VCCSPN

Note for documenting:1. For transcribing doctor’s order to use red pen to place the time when the STAT med is

given and your initial. On MAR for the STAT med, after writing the medication put the time and your initial in the right column then put a straight line, this is to prevent for someone to add anything for the STAT you had given.

2. For those Humulin N and R to put an indication that it is on HOLD. For the reason that patient has hypoglycemic attack. You don’t want his sugar to go low anymore.