NURSING PROCESS RECORD
NUR 203
Psychiatric Nursing
In narrative form discuss:
Patient relevant past psychiatric history: patient is a 39 year old female with a history if psychosis, depression, and bipolar disease. She had two psychotic episodes, one 14 years ago and another one a year ago. She was admitted with diagnosis of psychosis and postpartum depression. When she was admitted she was violent and was hitting walls and doors causing her self trauma. She stated she feels tired, sleepy, and has muscle weakness. She stated that she doesn’t want to harm herself now. She stated that the reason she got depressed and had a psychotic episode is the birth of a baby girl (2.5 month prior to admission) and because she was “thinking too much.” She said she didn’t have problem raising her older children (teenagers now) because her parents were helping her. she moved to New York 10 years ago, her mother stayed in Chicago, her father passed away 6 years ago. She thinks that loose of support system caused the break down.
Behavior on admission, type of admission: on admission patient was violent hurting herself by hitting walls and doors. She has 3 wounds (on right arm and on both legs) that she acquired during violent outbreak. Her husband brought her to the hospital after she started getting violent at home. she was initially in 4 point restraint until she fell asleep.
support systems outside of hospital: she moved to New York 10 years ago, her mother stayed in Chicago, her father passed away 6 years ago. She thinks that loose of support system caused the break down. She stated it was hard to build new relationships and find new friends when she moved to New York. She stated her husband and 3 older children will be helping her take care of the baby.
social history/ support system: Patient lives at home with husband, 3 teenage children and a new born daughter. She works in nursing home as nursing assistant. And rebuild her network of friends that she lost after she moved.
medication history: Haldol 5 mg po at bedtime, Liquid Lithium 300 mg/5ml, 5ml po TID
discharge planning: patient was discharged on 11/26/08. She was going back home and her family will be helping her.
Nursing notes: Patient A&O X 3 . Calm, cooperative and sleepy. Mood- neutral. Denies desire to hurt self and others.. Patient compliant with medications. Appearance- hair is not combed clothes is dirty. Attended group activity on 11/25 but didn’t communicate a lot on 11/26, stated she is very sleepy. Ambulates at lib. Diet-normal. Safe and therapeutic environment maintained.
AXIS I-Primary psychiatric diagnosis
AXIS I- postpartum depression
AXIS II- Secondary psychiatric diagnosis
AXIS II- none


EXPECTED BEHAVIORS
ACTUAL BEHAVIORS
Appearance – lack of grooming. Appears tired
Appearance- hair is not combed, close is dirty, sitting with her eyes closed.
Motor behavior-slow, muscle weakness.
Motor behavior- passive, appears sleepy and complaints of muscle weakness
Mood- sad, fearful, euphoric, neutral, hopeless, adhendonia, angry, and irritable, frustrated
Mood- neutral

Affect-blunted or flat, withdrawn, anxious, negative
Affect- flat, indifferent.

Speech- slow speech, tone – normal, soft,
Speech- slow, soft

Perception-guilt, fear, hurt
Perception- fear of taking care of a baby by her self.
Thought content-negative thoughts, denial, unrealistic.
Thought content- denial.
Thought process- pessimistic
Thought process: illogical


Sensorium- normal

Sensorium- normal


Insight/ Judgment- relevant and appropriate
Insight/Judgment- poor understanding of cause of depression. Stated she was got depressed because she was thinking too much

Interpersonal behaviors-withdrawal,

Interpersonal behaviors- cooperative, calm
Hx. Suicide attempts/assaults- suicidal ideation, suicidal plan, suicidal method
Hx. Hurt self but stated that had no intentions to kill self. Threw her self at walls and doors causing bruising and abrasions on right arm and bilateral legs

NUTRITION WORKSHEET
NUR 203
1. Patient’s age – 39 years old , Gender-Female

2. Height - 5’7” , Weight 225 lb.

3. Ideal body weight for a person of this age, sex, and height( from the textbook)

35.2

4. Compare the patient’s actual weight to the ideal body weight and draw a conclusion- Patient is obese
Guide for BMI Evaluation-
The normal BMI for female with patient’s measurements is 20-25.
31-40- moderately to severely obese.
5. Identify any stressors that the patient has that might impact on the patient’s nutritional needs.
Recent birth of a child “has to eat for two”
Patient is an African American female
Patient stated she likes eating and she eats when she is sad
Medications: one of the side effects of Haldol is dry mouth. Lithium has a side effect of nausea/vomiting, dyseusia (taste distortion) salty taste, swollen lips, dental caries.


Medical history-psychosis, bipolar, depression recent child birth (2.5 month prior to admission.
Several studies have found weight to be linked with depression. Some patients experience weight loss, some may experience weight gain.
While researchers have found a connection between depression and weight gain, they have not been able to determine the direction of the connection .In other words, they have not been able to demonstrate that excess weight causes depression or that depression causes excess weight. Several theories , however, could support either direction. For example, depression could lead to excess weight because of overeating-using food as a comforting tool and because of less physical activity- feeling very tired and having no energy. On other hand , being obese could lead to depression. There is a stigma attached to being obese, which is often accompanied by of negative and hurtful comments.
Child birth can lead to weight gain. In many cultures it’s tought that the mother has to eat twice as much in order to have nutrients for the child to develp.
Psychosis can cause violent behavior and increased activity which requires more energy.
6. What adaptations does the patient exhibit indicating a nutritional problem (actual or potential)?
Patient’s BMI indicates that she is moderately obese
It can cause heart disease hypertension and increases chances of diabetes. Lab results indicate blood glucose level within a normal range, patient’s blood pressure was within a normal range on admission. Cholesterol level was not checked during this hospitalization. Although she doesn’t have diabetes and hypertension now, she has increased chance of getting it in the future.
7. How many calories is the patient receiving in a 24 hour period-
Calories count was not performed.

8. What type of hospital diet is your patient on, and what is provided on that diet?(Use nutritional manual)

Patient is on –normal diet. Patient had a lot of carbohydrates, fats and proteins during thanks giving lunch. She needs a decrease in caloric intake and low fat diet in order to loose weight. Eating fruits instead of juice and eating vegetables will benefit nutritional status by providing a low calorie snack as well as a lot of vitamins. Increasing amount of fiber in the diet will be beneficial as well. It will prevent constipation and help loose weight. Using Food Guide Pyramid will help balance diet for patients personal nutritional needs.
I f your patient is on a nutritional supplement, list 3 important ingredients that will help your patient- None
Evaluate patient’s actual % of intake.
100% of her meal. Plus frequent snacks
List specific nursing interventions including teaching to assist your patient to meet nutritional needs
Oral care is very important in nutrition. Lack of hygiene can cause taste disturbance. Due to side effects of medications patient is taking, she might have dry mouth, which will effect appetite.
Supplementing some foods for healthier alternative will help reduce weight. For example whole wheat bread will be healthier alternative to white bread. Fat free or 1% fat milk can also help reduce weight
Exercise help not only reduce weight, but will prevent heart disease as well. Developing muscles will increase metabolic rate.
DEVELOPMENTAL WORKSHEET
Nursing 203
1. Patient’s age and gender- Age-39 , Gender- F
2. Erickson’s stage for age of patient(theory)
Adulthood
3. Central tasks of #2
Generativity vs stagnation
4. Behaviors that indicate negative resolution of this Developmental phase (from Psych text). Self-indulgence, self concern, lack of interest and commitments
5. Developmental level at which your patient is functioning and adaptations which support the developmental level.
Adolescence: identity vs. role confusion. Plans to actualize self. Wants to go to college and become an LPN. Feeling of confusion and indecisiveness. Avoidance of life style commitments.
6. SPECIFIC nursing interventions to prevent regression/ to maintain present level of function( at least 5)
- Use therapeutic communication techniques. Show empathy and real concern
- Advise the patient to comply with meds and group therapy during and after discharge
-Encourage the patient to be actively involved in planning her social life outside the hospital
-Encourage the patient to explore her feelings about her family
# Priority – 1

Nursing Problem Statement:
Risk for violence self directed related to disturbed thought process secondary to psychosis.
Short term goal: patient will not hurt self while in my care

Long term goal : patient will not have another violent outbreak for 10 years as evidence by patients report.

NSG. INTERVATIONS(in priority order)
RATIONALE
EVALUATION
1.Put 4 point restrain during violent outbreak

2. administer Haldol 5 mg po at bedtime

3.Administer Liquid Lithium 300 mg/5ml, 5ml po TID

4. Remain calm

5. do not approach a violent individual alone

6.reduse noise

7 . remove individual from situation if environment is contributing aggressive behavior

1. 4 point restraint is not allowing patient hurt self, restraining patient when patient is not violent will limit freedom and is unnecessary.

2. Haldol is a dopaminergic blocker and an antipsychotic.

3. Lithium is an antimanic medication, given to treat manic episodes of bipolar disorder. During manic episodes patient can harm self. Perception of own abilities might be distorted during such episodes, which can lead to self harm

4. patient can feel when others are anxious and might become more anxious. This can lead to more violent outbreaks.

5. presence of three or four staff members will be enough to reassure the individual that you will not let him or her lose control.

6. quite environment reduces agitation.

7 anxiety can be contagious and can lead to violence

1 patient didn’t have violent outbreaks while in my care. She was put in 4 point restrain during first day of hospitalization. After being restrained for a few hours she fell asleep and restraints were removed. Patient bruised arm and both legs before restraints were used. Skin break down was minimum.

2. patient didn’t have psychotic episodes after she started taking Haldol. Medication caused some side effects such as dry mouth, drowsiness, insomnia, headache, weakness. Patient understood the need to take them and said that these medication helps her.

3. patient stated she is taking this medication because it helps her. she did however say she doesn’t get manic. She just gets sad and starts hitting walls when she thinks too much. Patient had muscle weakness which is be a side effect of this medication.

4. patient remained calm while in my care. She stated she is not anxious and is happy she can go home.

5. patient didn’t have violent outbreaks while in my care.

6. patient didn’t have TV in her room. although she was shearing room with others, her roommates were sitting in front of a nurses station. Patient was able to stay in her room by herself. She remained calm while in my care.

7. patient went to her room when another patient started shouting. She was aware of her own level of agitation and knew that hearing others scream will get make her more anxious and agitated. She wanted to stay calm so she would go home.

# Priority – 2
Risk for Impaired parenting related to interruption of bounding process secondary to postpartum depression.
Short term goal: patient will acknowledge a problem with parenting skills
Long term goal: patient will not neglect or abuse her new born daughter as evidence by patient’s husband’s report.
Nsg. Interventions ( in priority order)

RATIONALE
EVALUATION
1. Establish rapport

2. provide information about age-related developmental needs.

3.teach relaxation techniques

4.Assess support system.

5. allow to express feelings about infant and provide an atmosphere of acceptance

6.encourage parent to meet basic self-needs

1. It is a process of establishing good will and trust.

2. athough patient already has 3 children, there is a 14 year gap between this child and the second youngest. patient was also helped to raise her three children by her mother. She is raising this child without strong support system she had before. If parent doesn’t know what is normal for a child, the parent may have unrealistic expectation for him or her.

3.relaxaton techniques help prevent psychotic episodes and depression which effects child-parent relationships.

4.Family and friends can help take care of the child as well as help to cope with depression.

5. it is normal for a parent to have negative feelings about a child, underlying feelings must be recognized.

6.it is exhausting to care for a child. A parent who is not meeting his or her own needs of rest, nutrition, and hygiene will ne ineffective in carring for the child

1. rapport was established, patient felt comfortable talking to me.

2. patient is aware of developmental mile stones, however she needed more information on age-specific care. After information was provided, she was able to explain why child needs to be bathed frequently and fed every 2 hours. She stated that because of increased rate of fluid exchange, infants have to consume liquids more often then adults.

3. Patient stated she will try guided imagery at home, said she is too sleepy to do it in the hospital

4. Patient stated she was helped by her parents to raise children in the past, however she is now living away from her mother. She stated that her husband and older children will be helping her raise the youngest child.

5. Patient didn’t want to talk about problems she encountered with this infant. She said that she loves her daughter and that children are fun and cute. She stated this is the first time she is raising a child without help of her parents.

6. Patient stated she will try to relax more. She said she will try to sleep more as well.

#Priority – 3

Sleep deprivation related to frequent awakening secondary to depression ans a new born child.
Short term goal :Patient will report sleeping at least 7 hours without waking up while in my care
Long term goal: patient will report an optimal balance of rest and activity a year after discharge.
Nursing interventions
Rationale
Evaluation

1. Reduce noise at night

2. Limit caffeine intake

3. limit day time napping

4. increase physical activity (not prior to bedtime)

5. bedtime routines

6. set a relaxing routine to prepare for sleep (e.g., herbal tea, warm bath)

7. limit alcohol intake

1. Noise interrupts sleep

2. Caffeine is a stimulant and will keep patient awake, interrupting sleep cycle

3. Day time napping can disrupt sleep cycle.

4. Physical activity prior to sleep will over excite patient and will not allow for proper sleep, physical activity during the day however can improve sleep.

5. Bed time routine helps regulate sleep cycle.

6. Relaxation prior to sleep allows falling asleep easier.

7. Alcohol intake can cause nightmares and frequent awakening

1. Patient stated that it is usually quiet at night in the hospital, only sometimes she can hear other patients talking. At home she can not sleep all night because the child wakes her up at least once a night

2. Patient didn’t drink beverages containing caffeine during hospitalization. She stated she will not drink caffeine containing beverages after discharge.

3. Patient was very sleepy due to lack of sleep and side effects of medications. She fell asleep in front of nursing station, however was unable to stay asleep for ore then 10 minutes. She didn’t nap after that.

4. Patient was helping prepare tables for thanks giving lunch and was walking around the unit. She was more awake after helping set tables.

5. Patient stated she was going to sleep at the same time during hospitalization. She stated she will try to keep the same schedule after discharge. She reported understanding that reading, watching TV and other activities should not be performed in bed. She stated that she will sleep in bed and if she cannot fall asleep, she will get up and try again later.

6. Patient stated she will try to take baths after discharge.

7. Patient stated she will not drink alcohol until her daughter is at least one year old and can

Impaired verbal communication.

CVA
Dementia
Said “what” after physical therapist continuously repeated her name
Primary nurse reported hearing her say “yes” and “no”
Moans when in pain
Closes her eyes when someone is looking at her.


Impaired communication r/t cognitive impairment

Cognitive impairment is any disorder that impairs cognitive functioning. It may affect the ability to use and understand language. The total loss of speech, impaired articulation, or the inability to find or name words may develop. It can also alter the ability to send, receive, or comprehend messages. When an individual experiences a decrease, delayed, or absent ability to receive process, transmit and use a system of symbols. Communication is impaired. According to Carpenito impaired communication is thestate in which an individual experiences or is at high risk to experience difficulty exchanging thoughts, ideas, desires, wants, or needs with others
Ms. CR had dementia and a history of CVA. Brain damage due to both of the diseases can impair communication. Pt. doesn’t verbalize her wishes and desires. She is able to articulate simple words, however really does so.
Pt. will use alternative method of communication WIMC.

1.Assess mental status
2. Assess developmental level.
3.. Assess pts. anxiety level
4.Establish Rapport
5.Maintain therapeutic
communication
5a. Using silence
5b. Using touch
5c. paraphrasing
5d. Offering self
5e. Listen attentively to pt.
5f. Offer support to pt. and caregiver
6. Identify alternative method of communication.
7. Refer pt. to speech therapy.

1. It reveals the clients general cerebral function. The functions it includes are intellectual and emotional.
(Kozier pg 642)
2. According to Erickson the developmental stage is adulthood and the task at this time is generativity VS stagnation. Those that achieve generativity are creative, productive, and concerned for others. Those that are in stagnation are self indulgence, self concern, with lack of interests and commitments.
(Kozier pg 353)
3. A person with mild anxiety can learn to alter lifestyle habits, more severe anxiety can be paralyzing. Pts. experiencing anxiety may be worried and therefore unable to focus on complete essential self care activities.
(Brunner pg 116)
4. It is an understanding between two people. It allows the client to have control over the communication, the purpose, subject matter, and pacing. It is an appropriate approach to gain information. It is a process of establishing good will and trust.
( Kozier pg 183 & 186)
5. It promotes understanding and can help establish a constructive relationship between the nurse and the client.
(Kozier pg 467)
5a.Allows the pt. to put thoughts together.
(Kozier pg 469)
5b. Providing appropriate touch reinforces caring feelings.
(Kozier pg 469)
5c.This conveys that the nurse has listened and understood the client’s basic message and also offers client’s a clearer idea what they have said.( Kozier pg 469)
5d. Suggesting your presence will allow you to understand the pt. without making any demands. (#6, 469)
5e. Allows you to pay attention to the total message, both verbal and nonverbal. It allows you to absorb both the content and the feelings the person is conveying. You listen to the pts. needs. It encourages pt. to communicate
(Kozier pg 468)
5f. It enhances exploration of feelings and let the clients and their caregivers know that the nurse acknowledge their feelings.
(Kozier pg 1089)
6. To determine how the pt. best receive messages i.e. by listening, looking, through touch, or an interpreter. It is often helpful to use alternative communication strategies such as word boards, pictures, or paper pencil.
(Kozier pg 479)
7. Speech therapy would be able to do their own assessment and establish a system of communication.
(Brunner pg 612)

1. Patient is alert and responds to her name. I was unable to establish orientation to time and place due to patient’s inability to communicate.
2. I assessed developmental to be older adult. Developmental task is integrity vs. despair. Pt. appears to be in despair. She understands simple statements and is able to articulate at least some words. (she said “what” after physical therapist continuously repeated her name) however, it appears she doesn’t want to communicate her wishes and doesn’t wish to respond to questions in other way.
3. Pt sees to be angry and wishes to be left alone. Was unable to assess emotional further due to lack of verbal communication.
4. I attempted to establish rapport by using therapeutic communication, however patient refused to communicate with me. It appears I was able to improve rapport on a second day. Patient closed her eyes as soon as she saw hospital stuff looking at her, however she kept her eyes opened when I was with her alone with curtain closed
5. I maintained therapeutic communication.
5a. I asked the pt how she is feeling and waited for response. She didn’t answer so I started asking more direct questions, such as “Does anything hurt you”
5b. I touched pt’s arm when talking to her. She didn’t pull her arm away when I touched her.
5c. Pt wasn’t talking to me, however I reacted to her actions by asking her questions about reason she does this. For example when she pulled her nasal cannula, I asked her if it feels uncomfortable and then expected nasal cannula and noticed it was too tight.
5d. I let her know that I am there for her in case she needs anything and every time I was leaving I reminded her that if she needs me, she can use a call bell.
5e. patient did not use verbal communication, however I paid close attention to nonverbal communication. I told the pt. I was going to feed her, she turned away and closed her eyes. This message showed me she doesn’t want to eat.
5f. I offered support and tried to explore feelings by asking about physical therapist, she seemed to be angry at him, I acknowledged her feelings and said that is must be hard to have people always telling you what to do and when.
6. I asked patient to squeeze my hand for “yes” and squeeze my hand twice for “no”.
7. I talked to the primary nurse about referral to speech therapy.
Goal not met. patient didn’t attempted to communicate with me, however the progress was present and if more time was given, I would be able to improve the communication further.

1. I was unable to determine orientation, however due to dementia; patient might not be oriented to time and place.
2. patient’s lack of desire to communicate is a barrier to communication.
3. anger is a barrier to communication and teaching. Anger has to be resolved prior to teaching alternative methods of communication.
4. rapport improved slightly, however it wasn’t improved enough for patient to open up enough to talk to me or even use alternative methods of communication in order to make her wishes known. If more time was given to establish rapport, I might’ve gotten her to respond to my questions.
5. Therapeutic communication techniques were not as successful as I hoped they would be, however they did help to establish rapport and improved communication.
5a. patient didn’t speak to me, however she became more relaxed, and did not get frustrated.
5. patient did not seem to react to touch. she did however resisted when people whom she never seen before would touch her.
5c. pt. became more calm and didn’t pretend to be sleeping as long as I was the only person in the room or the curtain was closed and she didn’t see anyone other then me.
5d. pt. did not ask me for help or used the call bell.
5e. I was able to understand when the pt. needs help and when she wants to be left alone by closely monitoring her nonverbal messages. This helped me to show the patient that I can help her whenever she needs it, yet I was not trying to invade her personal space.
Patient was more relaxed after she saw that I’m only there to help
5f. patient turned away from me and pretended to be asleep when I started acknowledging her feelings. She seemed to be upset. Although she got upset, I don’t think she was upset about me asking her about it but rather she was upset because she remembered about the way she was treated.
6. this intervention was not successful, how ever if I had more time to establish rapport, she would be more likely to communicate.
7. nursed stated that she will refer the patient to speech therapy. It is unclear how well the patient can articulate verbal message. However it could be the case since patient has a history of CVA.

This NPR is on risk for aspiration. I passed it and was told it's perfect, but i passed it with the easiest instuctor ever.

Dysphagia
CVA
Pure/ thickened fluid diet
Dementia
Unable to elevate upper body
Poor oral care
Depressed gag reflex

Risk for aspiration related to depressed laryngeal and glottic reflexes secondary to CVA

Cerebral vascular infarction results when an area of the brain loses blood supply because of vascular occlusion. One of the signs of CVA is inability to swallow due to depresses laryngeal and glottis reflexes. (#7, 530) Depressed laryngeal and glottic reflexes places person at risk for aspiration. Risk for aspiration in the sate in which a person is at risk for entry of secretions, solids, or fluids into the tracheobronchial passages (#1, 247)
Ms. CR has a history of CVA and has dysphagia, this places her at risk for aspiration.
Patient will not aspirate while in my care as evidence by absent adventitious breath sounds.

1.assess level of consciousness.
2. Position patient in a high Fowler’s position (head of the bead elevated at least 45degrees)
3. Provide pureed and thick liquid diet
4. Provide oral care following each meal
5. Auscultate the lungs
6. place suctioning equipment at the bedside
7. Assess vital signs
7a. Assess blood pressure
7b. Assess respiration.
7c. Assess pulse
7d. Assess temperature.
8. Educate patient/ family about aspiration precautions.
9. Obtain WBC count
10. Assess oxygen saturation.
11. Assess mental status
12. Assess skin color

1.A decreased level of consciousness is a prime risk factor for aspiration
2. Patients with neuro-muscular dysfunction may not be able to change position most congruent to maintaining their airway.
3. Pureed and thick liquids are easy to swallow. This diet is often ordered for patients who have difficulty swallowing. Thick fluids have a slower transit time and allow more time to trigger the swallowing reflex(#6, 522)
4. it is important to remove residual from the mouth of the patient who is suffering from dysphasia as it can cause them to aspirate. Pocketed food can be easily aspirated at a later time (#9, 1298)
5. Stridor can be an indication of lower airway obstruction. (#3, 1298)
6. Suctioning may be necessary to clear the airway passage. (#3, 1318)
7a. Unusual increase in blood pressure may be a sign of hypoxia (#7, 724)
7b. tachypnea/dyspnea are signs of hypoxia.(#9, 724)
7c. Dysrhythmia is a sign of hypoxemia. Hypoxemia usually leads to hypoxia, which is life threatening. Tachycardia is a sign of hypoxia. (#9, 724)
7d. Patients with certain types of pneumonia (aspiration pneumonia) usually have a sudden onset of chills and rapidly rising fever (38.5 to 40.5 C or 101 to 105 F) (#7, 636)
8. Aspiration of gastric contents causes a chemical burn of the tracheobronchial tree and pulmonary parenchyma. An inflammatory response occurs. This results in the destruction of alveolar–capillary endothelial cells, with a consequent outpouring of protein-rich fluids into the interstitial and intra-alveolar spaces. As a result, surfactant is lost, which in turn causes the airways to close and the alveoli to collapse. Finally, the impaired exchange of oxygen and carbon dioxide causes respiratory failure. (#9, 681)
9. WBC's protect the body from invasion by foreign objects. WBC count is often elevated if infection is present. Pneumonia can be caused by aspirated food (#9, 872)
10. Pulse oximetry is performed to determine the need for oxygen and to evaluate the effectiveness of the therapy. Pulse oximetry can help to determine the need for oxygen therapy. Decreased oxygen saturation is a sign of hypoxia which could be caused by blockage of airway(#9, 638)
11. Changes in mental status, such as impaired judgment, agitation, disorientation, confusion, lethargy, and coma are signs of hypoxia. If hypoxia is not identified and treated early many complications and even death may occur. (#9, 724)
12. cyanotic nail beds are demonstrating central cyanosis (A late sign of hypoxia) (#7, 636)

1. I assessed patient to be alert. She responded to her name by opening her eyes.
2. I elevated the head of the bed 45 degrees when patient was at rest and 90 degrees during meals.
3. I attempted to feed patient on 4/23 with puree food and thickened liquids, however she pretended to sleep as soon as she hear me saying I was going to feed her. She ate breakfast on 4/24. Her meal was pureed and liquids thickened.
4. I provided oral are after breakfast. There was no residual left in the mouth
5. I auscultated lung sounds. Pt. had clear lung sounds
6. Suctioning equipment was kept at a bedside.
7a. I assessed blood pressure to be 132/72 on 4/23 and 128/65 on 4/24
7b. I assessed respirations to be 18 regular, non labored , deep on 4/23 and 20 on 4/24
7c. I assessed pulse to be 83 on 4/23 and 88 on 4/24
7d. I assessed temperature to be 98.9 on 4/23 and 99.2 on 4/24
8. I was unable to teach the patient about aspiration precaution due to dementia. I explained to pt’s daughter that she shouldn’t feed her mother by her self, since she cannot use suctioning equipment in case the pt. aspirates.
9. WBC count was 11.6H on 4/22, 12.3H on 4/23, 13.9H on 4/24
10. I assessed pulse oximetry to be 96% on
4/23 and 97% on 4/24
11. Patient is alert and responds to her name. I was unable to establish orientation to time and place due to patient’s inability to communicate.
12. I assessed patient’s skin to be pink

1. Pt. is alert and therefore this factor is not contributing to risk for aspiration.
2. Patient did not aspirate during meals and there was no stomach content in the lungs by the evidence of clear lung sounds.
3. Patient tolerated food well and didn’t aspirate.
4. patient did not aspirate residual left from the meal
5. Pt. doesn’t have airway obstruction caused by aspiration.
6. Patient did not aspirate while in my care, therefore suctioning equipment was not used. However if patient would’ve aspirated, suctioning would’ve cleared airway.
7a. patient’s blood pressure is slightly elevated; however it is not unusual for this patient since she has a history of HTN. Other assessments are needed to determine presence of hypoxia
7b. respirations are within a normal range which shows that pt. is not experiencing hypoxia.
7c. pulse is within a normal range, therefore pt. is not experiencing hypoxia and have not aspirated.
7d. temperature is slightly elevated, therefore an infections process is suspected. Thee is a possibility of aspiration pneumonia. To determine cause of temperature elevation more assessments are needed.
8. Daughter stated she will not feed her mother unless appropriate personnel is in the room.
9. elevated WBC count is an evidence of infection. This result is consistent with other findings (elevated temperature). Although there is a possibility of aspiration pneumonia, due to clear lung sounds, I believe this infection is of other origin
10. Patient is not experiencing hypoxia, therefore she did not aspirate
11. I was unable to determine orientation, however due to dementia; patient might not be oriented to time and place. Other assessments are needed to determine hypoxia
12. patient is not experiencing hypoxia

Brunner text book can be found online, so you don't have to retype all the information. Just go to http://thepoint.lww.com/smeltzer11e you just have to use a code in your textbook (there is a "scratch off below" square) to register.

Imbalanced nutrition

Dementia
Hypothyrodizm
Confusion
Depression
Dry oral mucosa
Requires assistance with feeding
OOB to the chair
Appears malnourished, able to feel bones through the skin
Poor appetite
Doesn’t like food served for breakfast and lunch


Nutrition imbalance less than body requirements r/t altered mental status secondary to dementia

For a diagnosis of dementia to be made, at least two domains of function must be altered—memory and at least one of the following: language, perception, visuospatial function, calculation, judgment, abstraction, and problem-solving. Because of inability to hake choices, person might have difficulty eating foods that are needed. Memory impairment can also affect nutrition, people with impaired memory might forget to eat and drink. (Brunner, 243)
According to Carpenito, Imbalance nutrition less than body requirements is the state in which an individual, who is not NPO, experiences or is at risk for inadequate intake or metabolism of nutrients for metabolic needs with or without weight loss.
Mrs. JG has dementia. She is confused and unable to make healthy choices. She doesn’t ask for food and has to be reminded to eat and drink.
Pt. will consume at least 25% of meal WIMC.

1.Assess v/s
2. Assess nutrition status
2a.Assess weight.
2b. record I&O
3.Place pt. on calorie count
4.Perform oral hygiene
5a.Provide pt. with proteins
5b. Provide pt. with carbohydrates (sugar, fiber, and starch.)
5c. Provide pt. with fats
6.Offer pt. small meals
7. Provide pt. with food preferences.
8. Provide pt. with appropriate environment.
9. Administer Seroquel
Assess for therapeutic and side effects. Teach about therapeutic and side effects of Seroquel
10a. Assess pts. mental status
10b. Assess pts. developmental level
10c.Assesses pts. orientation and level of consciousness
10d.Assess pts. level of anxiety
10e. 17.Teach pt. about nutrition
11. Administer Zithromax. Assess for therapeutic and side effects.
12. Provide pt. with supplement
Ensure PO TID
13.Refer pt. to dietician
14. Assist patient with feeding, open the containers.
14.Obtain Pts. labs
a.HGB
14b.albumin
14c. transferrion
14e. calcium.
14f. sodium
14g.potassium

1. A change in vital signs may indicate fluid, electrolyte, and acid – base imbalances. Tachycardia is a sign of hypovolemia. Irregular pulse may occur from electrolyte imbalances. An elevated temperature may be a result of dehydration or a cause of body fluid loses. Changes in the respiratory rate and depth may cause acid- base balances. Blood pressure may fall with FVD, hypovolemia, or increase with FVE. When a person’s temperature is elevated, hypermeatabolism occurs, and the respiratory rate, heart rate, and basal metabolic rate all increase.
(Kozier pg 1447, Brunner pg 101)
2. A nutritional assessment will identify clients at risk for malnutrition and those with poor nutritional status.
( Kozier pg 1252)
2a. Daily weight is an accurate measurement of pts. fluid status. Significant changes in weight over a short period of time are indicative of fluid changes.
(Kozier pg 1446)
2b. The measurement and recording of all fluid intake and output during a 24hr. period provides important data about the client’s fluid and electrolyte balance.
(Kozier pg 1447)
3. The body obtains energy in the form of calories from carbohydrates, protein, fats, and alcohol. When using a tool to measure intake it allows judgment of overall adequacy and when specific foods or nutrients are suspected of being deficient or excessive.
(Kozier pg 1237 and 1257)
4. Oral hygiene improves the pts. appetite, and improves pts. ability to taste.
( Kozier pg. 1263)
5a. Proteins in the diet provide amino acids necessary for growth and repair of animal tissue.
(Kozier pg 1233)
5b. Carbohydrates are a basic source of energy. Sugars are the simplest of all carbohydrates, are water soluble and are produced by both plants and animals.
Starches are insoluble non sweet form of carbohydrates. Fiber is a complex carbohydrate derived from plants, supplies roughage, or bulk to the diet.
(kozier pg 1232)
5c. Fats are a form of potential or stored energy. Fats are also protein spearers. And provide insulation for heat loss. Fat is needed for absorption of sat soluble proteins
(Kozier pg 1233)
6. Smaller meals help improves pt. appetite and does not discourage pt. from eating.
(kozier pg 1263)
7. Offering a pt. their food preference will improve pts. appetite with the pt. being familiar to food.(Kozier pg 1263)
8. A tidy clean environment that is free of unpleasant sights and odors will improve appetite.
(kozier pg 1263)
9. Treating schizophrenia or bipolar disorder. It may also be used for other conditions as determined by the doctor.
Seroquel is an atypical antipsychotic. Exactly how it works is not known. It affects certain receptors in the brain. This may help to improve symptoms associated with schizophrenia and bipolar disorder. Severe allergic reactions: (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); confusion; fainting; fast, slow, or irregular heartbeat; fever; increased saliva production or drooling; increased sweating; memory loss; menstrual changes; muscle pain, weakness, or stiffness; new or worsening mental or mood changes (eg, depression, hallucination); numbness or tingling; persistent, painful erection; seizures; severe or prolonged dizziness or headache; shortness of breath; swelling of the hands, legs, or feet; symptoms of high blood sugar (eg, increased thirst, hunger, or urination; unusual weakness); tremor; trouble concentrating, speaking, or swallowing; trouble sitting still; trouble walking or standing; uncontrolled muscle movements (eg, arm or leg movements, twitching of the face or tongue, jerking, or twisting); vision changes.
(#10)
10a. It reveals the clients general cerebral function. The functions it includes are intellectual and emotional.
(Kozier pg 642)
10b.According to Erickson the developmental task at this time is ego VS. despair. People who obtain ego integrity view life with a sense of wholeness and derive satisfaction from past accomplishments. They view death as an acceptable completion of life. People who experiences despair often believe they have made poor choices during life and wish they could live life over.
(Kozier 416 and 417)
10c Establishing pts. orientation determines if the pt. has the ability to recognize other persons, awareness of when and where they presently are, and who they are themselves.
level of consciousness can lie anywhere a long a continuum from a state of alertness to a coma. A fully alert pt. responds to questions spontaneously and a pt. comatose may not respond to verbal stimuli.(Kozier pg 643)
10d.A person with mild anxiety can learn to alter lifestyle habits, more severe anxiety can be paralyzing. Pts. experiencing anxiety may be worried and therefore unable to focus on complete essential self care activities.
(Brunner pg 116)
10e. Adequate nutrition provides the body with nutrients. Nutrients have three major functions: providing energy for body processes and movements, providing structural material for body tissues, and regulating body processes.(Kozier pg 1232)
11. Treating infections caused by certain bacteria.
Zithromax is a macrolide antibiotic. It slows the growth of, or sometimes kills, sensitive bacteria by reducing the production of important proteins needed by the bacteria to survive. Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); bloody stools; chest pain; dark red raised areas of the skin; hearing loss; pounding in the chest; ringing in the ears; severe diarrhea; stomach cramps/pain; yellowing of the skin or eyes. (#12)
12. Nutritional supplements are often given to pts. Who are malnourished or have poor eating habits. They are high in protein and potassium.(kozier pg 1455)
13. A dietitian has special knowledge about diets to maintain health. A dietitian may design special diets to meet individual needs of pts.(Kozier pg 106)
14. Some clients are unable to open lids of containers of even to hold a spoon. They require assistance. (kozier, 1236)
14a. Low hemoglobin may be evidence of iron deficiency anemia.(Kozier pg 1258)
14b. A low serum albumin level is a useful indicator of prolonged protein depletion.
(Kozier pg 1259)
14c. Transferrin responds more quickly to protein depletion than albumin. Transferrion levels below normal indicate protein loss, iron deficiciency, hepatitis, and liver dysfunction.
(kozier pg 1259)
14e. A depletion of calcium can cause tetany with muscle spasms and paresthesias and can lead to convulsions.( Kozier pg 1441)
14f. Regulates water balance and assist in nerve impulses and muscular contractions.
(Kozier pg 1438)
14g. It is vital to normal neuromuscular and cardiac function.
(Kozier pg 1438)

1.I assessed VS to be
BP – 125/62
HR – 78 regular bounding
RR 22, regular deep, not labored
T 97.8
2. I assessed nutritional status (results below)
2a. Wt – 98lb
Ht – 5’2
2b. Intake – 60 oz of water while in my care.
Output – unable to determine due to incontinence. I&O wasn’t preformed by staff
3. Calorie count was performed daily, according to record pt was ingesting about 1500.
4. I performed oral hygiene before I tried to feed the patient.
5a. patient was provided with ensure pudding and pureed cheeseburger. She ate cheeseburger, but refused to eat ensure
5b. patient was provided with mashed potatoes, orange juice and apple sauce for lunch. She had apple juice left from breakfast. She ate mashed potatoes and asked to put a straw in her juice, but didn’t drink it when I was there. She refused to eat apple sauce, ate one spoon and said it doesn’t taste right. I brought fresh apple sauce but she refused to eat it she also had pureed vegetables, but only ate one spoon, she might have eaten more after I left, but she didn’t seem to like them.
5c. pt’s lunch had a lot of butter, meat, mashed potatoes and vegetables all had butter on them
6. I provided the patient with small frequent meals. I gave Mrs. JG ensure and apple sauce, which she refused. I removed some items from the tray and put it away for later.
7. I was unable to provide the pt. with food preferences, but to her confusion. She tried to explain to me what she wanted, but was unable to express her thoughts. I asked her about foods that were served and removed from the tray foods she said she didn’t want.
8. I provided am care and checked whether or not patient was incontinent before meal was served. Bed pans were not in sight and no foul odors were present. Patient was sitting in the chair during lunch instead of sitting in bed
9. Primary nurse administered Seroquel. Unable to determine effectiveness due to lack of time and information about condition prior to medication administration.
Patient didn’t have signs of side effects. Pt. was oriented to time only, was confused. Therefore teaching couldn’t take place.
10. I assessed mental status. Patient had dementia and depression. She expresses desire to die
10b. I assessed developmental level to be older adult and negative resolution of integrity vs. despair task. She appears hopeless and stated that the only thing she can do is to die.
10cPatient is alert and oriented to time only
10d Patient is anxious about “bumps” she found on her body and about inability to express her thoughts (moderate anxiety)
10e. Unable to teach due to patient’s lack of ability to retain information.
11. Zithromax was administered by primary nurse. No signs of allergic reaction are present. Unable to determine effectiveness due to lack of lab data. However I would’ve obtained C&S studies and WBC count to determine effectiveness of this medication. Teaching was not initiated due to patient’s inability to learn new information
12.Patient was provided with Ensure pudding TID, however she didn’t like the taste and refused to eat it
13. Pt. had a dietary consult which determined dysphasia and FTT
14. I opened containers and placed them closed to the patient, pt. was able to hold the spoon and feed herself.
14. Was unable to access results of lab work due to patient’s discharge, however I expect to find RBC and HGB to be low (patient has anemia).
No signs of calcium imbalance was present, therefore I expect Ca to be within a normal range.
Patient was dehydrated which could be a sign of Na imbalance.
I would pay careful attention to potassium level since patient is presenting some signs of potassium depletion (generalized weakness) potassium imbalance can also be very dangerous due to it’s effect on the heart muscle.
Albumin and transferrin should be within a normal range if the pt. was consuming as much protein as she was while in my care. Transferin levels could be outside of normal range due to possible iron deficiency which could be a result of anemia.
Goal not met. I encouraged pt. to eat. I explained the importance of eating however, pt. refused. Pts. appetite remains poor.

1.Pt’s vital signs present no change in nutritional status
2. Patient is underweight and isn’t consuming enough fluid. Fluid is needed to digest food, therefore it is important to increase fluid intake
3. Patient isn’t ingesting enough calories, and has to be encouraged to ingest more.
4. Pt. refused to eat ensure pudding and apple sauce after oral care, stated it didn’t taste right, however ate lunch.
5a.Patient had proteins needed. I didn’t see how much of the meat served she ate, but she seemed to eat meat before any other part of her lunch. I am unaware what she had for breakfast and dinner, but it the pt had as much protein intake during those meals as she had for lunch, she had digested daily protein requirements even though she didn’t have ensure.
5b. patient had some carbohydrates, however should eat more. Carbohydrate intake can be increased by providing juices, however it is harder to increase intake of complex carbohydrates. Fiber supplement has to be considered.
5c. pt. consumed enough fat to absorb vitamins. She shouldn’t eat too much fat to prevent complications of HTN, such as deep vein thrombosis. However she should eat enough lipids to increase weight and prevent heat loss.
6. Patient agreed to try to eat ensure and apple sauce, but after trying them, refused it. When lunch was served, she stated she cannot eat so much, but was more willing to eat after some items were removed from the tray. Unfortunately I can not be sure items I removed from the tray were later given to patient, but even if they weren’t, removing them helped to increase intake since patient wasn’t as overwhelmed be the amount of food she was seeing. It also helped to eliminated least need foods, such as simple carbohydrates.
7. Pointing out foods and asking the pt. whether or not she liked it worked much better then asking her what she liked. She became very aggravated when she was unable to explain what she wanted, but was calm when I was asking her which foods from the tray she wanted to eat.
8. Patient seemed to eat well and seemed comfortable.
9. Patient is confused, but able to follow the commands and make decisions. Although Seroquel proved to be effective in treating depression, Mrs. JG appears to be depressed and hopeless.
10a.Due to dementia, patient I unable to learn. Patient is confused and therefore cannot retain information provided
10b. Pt. can not be taught due to lack of desire to return to maximum level of activity.
10c. patient can not be taught due to confusion
10d. patient is too anxious to learn
10e. If the teaching would’ve taken place, I would have determined effectiveness of learning by asking questions about nutrition and in long term observed for healthy food choices according to content taught.
11. Not enough time was given to determine effectiveness of Zithromax in decreasing caloric requirements, however, over time I would expect weight gain.
12. Different flavors have to be offered to determine preferences and encourage pt. to eat.
13. Pureed diet was ordered for the pt.
14. Pt. was able to eat and started to ask me to open certain containers and to put a straw in juice. It appeared she had difficulties holding the spoon, but I didn’t try feeding in order to promote ability to care for self.
14. This lab values would be helpful in determining possible supplements patient might need as well as effectiveness of treatment and other factors that could contribute to malnutrition.

This is my OR/PACU. I didn't get it back yet, but i will add all the comments i got for it as soon as i'll get it back.
1. Identify 5 of the 6 types of stressors that patients experience during the perioperative period. Give at least one example of each type.
1. Physical: positioning and incision
2. Microbiological: risk for infection due to a break in the first line of defense and antibiotic therapy
3. Developmental: neonates/infants (small blood volume and limited fluid reserves), older adults (decreased kidney function and lower percentage of body water)
4. Psychosocial: Vegan (limited protein sources)
5. Physiological: Obesity (takes longer to heal), diabetes
2. Based on what you have observed in the OR/PACU, identify two priority nursing diagnoses for perioperative care at the following times.
a. Twelve hours pre-op
1. Deficient Knowledge related to lack of education about perioperative process.
2. Fear related to loss of control during anesthesia.
b. Intra-operative period
1. Risk for infection related to break in the first line of defense secondary to surgery
2. Ineffective protection related to effects of anesthesia secondary to surgery
c. One hour post-op.
1. Ineffective breathing patterns related to effects of anesthesia secondary to surgery
2. Risk for injury (bleeding) related to incision secondary to surgery.
3. Identify three ways the nurse maintains asepses in the operating room.
1. Assesses the surgical site for moles, warts, rashes, and other skin conditions, and prepares surgical site with antimicrobial agents.
2. Draping the patient with sterile drapes.
3. Assesses sterile field for breaks in sterility (holes)
4. Identify three ways the nurse maintains electrical safety in the room
1. Removing faulty equipments
2. Assure equipment is plugged in correctly (right circuits)
3. Assure proper placement of electrical equipment.
5. Identify three additional safety measures used in the OR/PACU
1. “Time Out” before the surgery begins
2. Counting all of the equipment
3. Proper positioning
6. Describe the commonalities of nursing interventions in the OR/PACU
Patient is position properly, patient’s safety is maintained by monitoring everything that is attached to the patient. Urine output is measured carefully and vital signs re monitored in both OR and PACU
7 Describe the differences in nursing care in the OR/PACU
Patient is able to protect him/her self during postoperative care, therefore less protection is
needed. Psychological support in needed during postoperative care, little communication done
during intraoperative period.
8. Identify two different positions a patient may be placed in during an operative procedure. Give
an example of an operation that require that position and identify an intraoperative and/or
postoperative nursing assessment for each position.
a. Position b. Example c. Nursing Assessment
1. Dorsal recumbent Hysterectomy Prevent hyperextension of neck
Assess sacrum for edema
Assess sacrum and heels for pressure ulcers
2. Prone Position Spinal surgery Assess for pressure ulcer on the
face
place pillow under the head to prevent flexion or hyperextension of the neck
support lower legs on a pillow or allow feet to fall naturally over end of the operation table to prevent foot drop
9. Identify two ways the OR/PACU nurse acts as a patient advocate
1. Preventing physical, electrical and microbiological hazards
2. Time Out (Identification of the patient and surgery site and type)
10. identify the criteria used to determine a patient’s length of stay in the PACU
Awake and oriented , able to maintain clear airway, deep breathing and coughing freely, VS are
stable or consistent with preoperative vital signs for at least 30 minutes. Protective reflexes
(gag, swallowing) are active. Able to move all extremities, adequate I&O, afebrile or febrile
condition has been attended to. Dressings are dry and intact; there is no overt drainage.
11. Discuss how this experience will affect the post operative care you give to your patients.
This experience gives a better understanding of complications the patient is experiencing. I was
able to visualize some of the stressors the patient is experiencing during intraoperative care. I
was able to see the changes in vital signs and their changes during the surgery. While seeing the
breathing patterns immediately after the surgery it became clear how important it was to
closely monitor breathing (respiration rate was changing rapidly for 3 to 50 breath/min in just a
few minutes. I was able to better understand the healing process after seeing the size and depth
of the incision.

This is my psychosocial NPR. I wrote it before professor McFadden explained to us what we had to include in it and surprisingly I passed. I did have a lot of comments on my process record, I’ll write everything she told me to change in the future.



Age 76 (o)
Stated she was diagnosed with COPD “a few month ago” (s)
Stated that uses oxygen at home (s)
Poor appetite, eats only yogurts (o)
New medications prescribed (o)
Has a soar on the gums from new inhaler (o)
Lives with daughter and daughter’s family (s)
Afraid to get OOB to the chair stated “I hope they know what they are doing putting me in the chair” (s)
Gets anxious when in unfamiliar place or with an unfamiliar person (RR 30 when she first saw me) (o)Asked about the difference between COPD, emphysema and Asthma (o)


Deficient knowledge related to new disease processes.
Patient with a new disease process needs to be educated about the disease and medications prescribed to treat the disease. Patient education is a major component of pulmonary rehabilitation and includes broad variety of topics (#7, 695)
Deficient knowledge is the state in which an individual experiences a deficiency in cognitive knowledge or psychomotor skills concerning the condition or treatment. (260)Mrs. AL was recently diagnosed with emphysema and was prescribed new medications. She expresses a desire to learn more about emphysema and Asthma. Displays deficient knowledge about treatments, such as oxygen therapy, inhalers and positioning.




Goal: The patient will understand her medical diagnosis and treatments by the evidence of ability to describe own disease processes, their treatments and importance of these treatments, while under my care.
1.Assess
mental status. (Level of consciousness and orientation)
2. Assess developmental level according to E. Erikson
3. Determine support system.
4. Determine insight into disability.
5.Obtaine education level.
6. Assess readiness to learn.
7.Establish trusting relationships by using verbal and nonverbal therapeutic communication such as restating or paraphrasing, focusing, summarizing and planning
8.Encourage to take Xanax 0.25mg PO prn TID
Teach patient about therapeutic and side effects.
Monitor for therapeutic and side effect
9.Encourge to ask questions
10.Provide positive feedback and avoid negative feedback
11.Teach the importance of proper positioning
12.Explain the disease processes of emphysema and asthma
13.Teach the importance of oxygen therapy, therapeutic effects and side effects
14. Teach proper use of Spiriva and Advair. Instruct to rinse mouth with water after using Advair


1. Assessment of mental status reveals the client’s general cerebral function. (#3, 642) Impaired cognitive ability may affect the client’s capacity for learning. (#3, 492)
2. Nurses can enhance a client’s developmental level by being aware of the individual’s developmental stage and assisting with the development of coping skills related to stressors experienced at that specific level. Nurses can strengthen client’s positive resolution of a developmental task by providing the individual with appropriate opportunities and encouragement (#7, 353) (Said I have to discuss specific level of older adult, explain + & - resolution.)
3. Social support has been demonstrated to be effective moderator of life stress. Social support also facilitates person’s coping behaviors; however, this depends on the nature of the social support. Emotional support from family and significant others provides love and sense of sharing the burden. Being a member of a group with similar problems or goal has a releasing effect on a person that promotes freedom of expression and exchange of ideas.(#7, 107) Spirituality helps people discover a purpose in life, understand the ever-changing quality of life, and develop their relationship with God or higher power. Spirituality is also a component of hope, and, especially during chronic, serious, or terminal illness, patient and their families often find comfort and emotional strength in their religious traditions or spiritual beliefs.(#7, 122) There are also cultural barriers to learning, such as language or values. To be effective, nurses must be culturally sensitive and competent; otherwise the client may be partially or totally noncompliant with recommended treatments. (#3, 492)
4.Learning is easier if a learner can connect the new knowledge to what they already know and have experienced (#3, 490) (Didn’t like rationale)
5. Because of decreased length of hospital stays, time constrains on client education may occur. Some of the education therefore will have to receive through reading. Patient’s ability is therefore important. Ability to use other sources, such as internet is also important. (#3,490)
6. Readiness to learn is the demonstration of behaviors or cues that reflect the learner’s motivation to learn at a specific time. For example if a patient is in pain or anxious she might not be able to learn. (#3, 490)
7.Lack of trust in patient-nurse relationship may create anxiety and interfere with learning.(#3, 489) Actively listening for the client’s messages and then repeating those thoughts and or feelings in a similar words conveys that the nurse has listened and understood the client’s basic message. Focusing helps the patient to expand on and develop a topic of importance. Summarizing and planning is useful at the end of an interview or to review a health teaching session. It often acts as an introduction to future care planning. (#3, 470)
8. Xanax is an anxiolitic; it is used to treat mild-to-severe anxiety. It is contraindicated for patients with renal or hepatic dysfunction unless no other options are available. Adverse effects include headache, dry mouth, blurred vision dizziness, hypotension, GI disturbances (e.g., nausea, constipation), jaundice, incontinency, urinary retention, rash, and leucopenia. (#4, 179)
9. Learning is faster and retention is better when learner actively participates. (#3, 490)
10. Positive reinforcement increases the probability of positive response to teaching and increases motivation (#3, 489). Negative feedback is viewed as a punishment and may cause the patient to avoid the person providing negative feedback in order to avoid punishment (#3, 491)
11. High Fowlers position is the position of choice for people who have difficulty breathing. It’s better to elevate the head of the bed or transfer a patient to the chair instead of placing an overly large pillow or more then one pillow behind the client’s head. this promotes the development of neck flexion contractures (#3, 1132)
12. One of the complications of emphysema is right-sided heart failure. Congestion, dependent edema, distended neck veins, or pain in the region of the liver suggests the development of cardiac failure. Patient should be aware of these complications (#3, 687). Complications of asthma may include status asthmaticus, respiratory failure, pneumonia, and atelectasis. Airway obstruction, particularly during acute asthmatic episodes, often results in hypoxemia, requiring the administration of oxygen and monitoring of pulse oximetry and ABG (#3, 711).
13. Suplemental oxygen is effective in prolonged survival of patients with COPD, however, when supplemental oxygen is administered at a rate higher then necessary, increased oxygen saturation results, and CO2is unable to be carried by hemoglobin or is cast off by the hemoglobin. This results in an overall increased load of CO2 in the body. (#3, 694)
14. Spiriva/Tiotropium is used to treat COPD, it is an anticholinergic agent. It works by enlarging the airways to allow easier breathing. Capsule is used with a specific inhaler and should not be swallowed. Capsules should not be exposed to air for long periods of time, if while removing the capsule, the second capsule was exposed to the air, it must be discarded. Some medicines may interact with Spiriva; therefore mouth should be rinsed after using this medication. (#8)
Advair/Fluticasone/SalmeterolFluticasone is a steroid. It prevents the release of substances in the body that cause inflammation. Salmeterol is a bronchodilator. It works by relaxing muscles in the airways to improve breathing.Advair is used to prevent asthma attacks. It will not treat an asthma attack that has already begun. To reduce the chance of developing a yeast infection in your mouth, rinse with water after using Advair. Do not swallow (#1)


1.Awake alert and oriented x3
2. I assessed developmental level according to E. Erikson.
3. Patient reported living with daughter and daughter’s family. Patient reported she is not a member of a support group. I didn’t refer her to the support group, but I should’ve informed her about lung association support groups in New York (American Lung Association of New York State -- Albany Office. 155 Washington Ave., Suite 210 Albany, NY 12210. 518) 465-2013 x300 and American Lung Association of New York State -- Long Island Office700 Veterans Memorial Highway Hauppauge, NY 11788. (631) 265-3848) Patient is roman catholic. She goes to the church where she can communicate with others and get support. (Left a huge comment about how great it was that I included it. So if u have McFadden, and want to make her happy with your NPR, include referral.)
4. I asked patient to explain to me all she knows about emphysema and asthma. Asked her to list medications she is taking and their effects.
5. Obtained education level. Education – high school. Patient can read, but stated she can not use internet.
6. Patient was too anxious to learn on Wednesday however was ready to learn on Thursday. She expressed desire to learn and felt less anxious after seeing me a many times over two days.
7. I established trusting relationships by using therapeutic communication techniques such as paraphrasing (so your daughter and her family moved in with you to help you out after your husband died), planning (lets review what you learned about use of your oxygen and you can then take a few deep breathes and try to cough), and summarizing (I will come back tomorrow and explain you more about ways to improve your breathing).
8. Xanax was not given due to low blood pressure, however the patient was not anxious when teaching was initiated and therefore was unnecessary.
9.I encouraged the patient to ask questions
10. I provided positive feedback when the patient was correctly summarizing learned information. I did not provide negative feedback
11. I explained the importance of proper positioning and explained that sitting in the chair would allow greater chest expansion and lung ventilation.
12. I answered patient’s question regarding the difference between COPD, emphysema and asthma. I explained disease processes of emphysema and asthma and listed complications patient might develop and should be aware of. I also explained that COPD places her at risk for pneumonia and she should be vaccinated in order to prevent it.
13. I explained the importance of proper use of oxygen therapy and explained why the patient should not increase oxygen flow unless necessary. I also reminded about fire safety.
14. I explained the proper use of Spiriva and Advair, reasons to receiving it, its action and the side effects. I instructed to rinse mouth after using Advair


1. Mental status indicates that the patient is able to learn and retain new information.
2. Older adult. Integrity vs. despair. Patient stated she is usually very active and takes care of grandchildren while her daughter is at work, however was in despair while hospitalized due to worsening of her condition. As condition started to improve, integrity was returned.
3. The patient can get more information from other members of the community; her family can also help her to find the information about new medications and disease processes.(Asked to elaborate on how I know her family can help her with internet use)
4. Patient knew very little about emphysema. She didn’t know the difference between emphysema, COPD and asthma. Patient listed all of her pulmonary medications and was able to list most of the side effects. This shows that she needs a lot of teaching about the condition while little education about medications is needed.
5. Patient is able to read the brochures about COPD and asthma, even though patient doesn’t know how to use internet, family can help her find the needed information online.
6. Very little teaching was done on Wednesday. Most of the teaching was done on Thursday when the patient was less anxious and more willing to learn.
7. Patient was not as anxious when talking to me as she was when she first saw me. Her respiratory rate decreased from 30 to 18. Patient was able to retain information better after trusting relationships were established.
8. If Xanax would’ve been given, I would’ve expected that patient would have change in respiratory rate, blood pressure and reported decrease in anxiety.
9. Patient asked questions about COPD, emphysema and asthma. Teaching proved to be more efficient when patient asked for the information, patient was more willing to learn.
10. Patient was willing to learn and retained information much faster then by the end of the day then she did when I first attempted teaching.
11. Patient stated “I suppose you are right, I will try to sit in the chair when physical therapist will come”
12. Patient reported understanding. Stated that she already was vaccinated last fall. She summarized received information and was able to list symptoms of the most serious complications.
13. Patient was surprised to find out that increased oxygen flow can be harmful, she stated she only uses oxygen at home only when she has to and will continue using it only when necessary unless her condition worsens. Reported understanding of fire hazards, stated that she no longer smokes and her family members don’t smoke inside the house.
14. Patient reported understanding, she stated that she always rinses mouth after receiving Advair, but doesn’t rinse after Spiriva Because she usually takes Spiriva right before Advair and they don’t interact.

She also wanted me to elaborate more on teaching nd give specific examples.


Bibliography
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2) Karch, Amy M. Nursing Drug Guide. Rochester: Lippincott Williams & Wilkins, 2008.
3) Kozier, B., Erb, G., Berman, A., Snyder, S., Fundamentals of Nursing Concepts, Process and Practice, 8th ed., new York, Addison-Wesley, 2008 (a/k/a Prentice Hall)
4) McCuistion, Linda E., and Kathleen J. Gutierrez. Saunders Nursing Survival Guide: Pharmacology. 2nd ed. St. Louis: Saunders-Elsevier, Inc, 2007
6) Pagana, Kathleen D., and Timothy J. Pagana. Mosby's Manual of Diagnostic and Labratory Tests. 2nd ed. St. Louis: Mosby, 2002.
7) Smeltzer, S., Bare, B., et al, Brunner and Suddarth’s Textbook of Medical Surgical Nursing, 11th ed., Philadelphia, J.B. Lippincott Co., 2008
8) "Spiriva." Drugs.Com. 8 Jan. 2008. 21 Feb. 2008 .