Thursday, November 15, 2012
Thursday, October 25, 2012
Saturday, October 6, 2012
Addition of Halogens to Alkenes
Addition of Halogens to Alkenes
Alkenes readily react with bromine and chlorine to form 1,2-dihaloalkanes (vicinal dihalides). In this reaction the π bond of the alkene reacts with the halogen to produce two new carbon-halogen σ bonds. The reaction is commonly carried out in an inert solvent such as CH2Cl2, CHCl3, or CCl4.
The mechanism for the addition of both bromine and chlorine is an electrophilic addition pathway involving an ionic intermediate. For both acyclic and cyclic non-conjugated alkenes this intermediate is a bromonium or chloronium ion. Nucleophilic attack of halide ion on one of the two electrophilic carbons of the bromonium (chloronium) ion gives the product.
The mechanism of the reaction of 2-methylpropene with bromine is shown below.
In the second step of the reaction the incoming bromide ion reacts with carbon on the side opposite the carbon-bromine bond that is being broken. The consequence of this reaction stereochemistry is seen most easily in cycloalkenes where only the trans dihalocycloalkane product is found. The addition of bromine to cyclopentene is a case in point:
In fact, it was the observation that the halogenation of alkenes involves this anti addition (the two halogen atoms add to opposite sides of the double bond) that led early investigators to postulate the existence of a halonium ion intermediate.Thursday, October 4, 2012
Tuesday, October 2, 2012
Friday, September 28, 2012
Wednesday, September 26, 2012
New York program allowing teens to get Plan B pill
Handing out plan B in a public school might not sound bad, however, the concern would be more about the ramifications to their bodies after taking these things. Do we know the damage they could cause by taking them even if they aren't having sex or even if they did, but didn't get pregnant. What is the risk involved? Would we see a rise in cancer because of it? who can answer those question.Furthermore, they were giving without parent permission. this is not the solution. we just open door to more problem such as infections and others. the more you provide to teen the further they tend to go.they have pills cost almost $30 now guess what they can sell them to however they want for extra money such as mom, aunt, big sister, cousin and stranger. Furthermore, it is a conversation piece between them and adult or stranger. moreover, nursing, teacher and however give them those might become closer to your child and even know more about their sex life than their parents. giving it to girls who have not yet had sex certainly sends a message. so take the time to think of a better strategy
Tuesday, September 25, 2012
Saturday, September 22, 2012
Sunday, September 9, 2012
Friday, September 7, 2012
Sunday, August 26, 2012
Wednesday, August 22, 2012
Care plan (NKA)
STUDENT’S
NAME______________________________________________________
DATES OF CARE ______________________________________________________
UNIT ASSIGNMENT_____________________________________________________
PATIENT’S INITIALS__WS______________SEX___________________AGE ________
OCCUPATION_______________________ADMISSION
DATE_________________
SURGERY
DATE____n/a____________________________________________________
ALLERGIES_____NKA_______________________________________________________
I. MEDICAL DIAGNOSIS:
- Chronic
obstructive pulmonary disease (COPD) is the overall term for a group of chronic
lung conditions that obstruct the airways in your lungs. COPD usually refers to
obstruction caused by chronic bronchitis and emphysema, but it can also refer
to damage caused by asthmatic bronchitis. In all forms of COPD, there's a
blockage within the tubes and air sacs that make up your lungs, which hinders
your ability to exhale. And, when you can't properly exhale, air gets trapped
in your lungs and makes it difficult for you to breathe in normally. COPD is
very common. It's a major cause of death and illness worldwide, and it's the
fourth-leading cause of death in the United States . In the majority of
cases, COPD is caused by long-term smoking and could be prevented by not
smoking or quitting smoking. However, once symptoms begin, the damage to your
lungs can't be reversed, and there's no cure. Treatments for COPD focus primarily
on controlling symptoms and preventing further damage. Initially, COPD is often
silent. Signs and symptoms may not appear until there's significant lung
damage, but once symptoms begin, they typically worsen over time. COPD symptoms
may include:
§ Persistent
cough
§ Increased mucus production
§ Shortness of
breath, especially during physical activities
§ Wheezing
§ Chest tightness
§ Frequent
respiratory infections
(http://www.mayoclinic.com/health/copd/DS00916,
retrieved 2-18-2009 )
II. SECONDARY DIAGNOSIS:
-
Chronic bronchitis is an inflammation of the main air passages (bronchi)
to the lungs, which results in the production
of excess mucous, a reduction in the amount of airflow in and out of the
lungs and shortness of breath. In
chronic bronchitis, there is excessive bronchial mucus with a productive cough
for three months or more over two consecutive years without any other disease
that could account for these symptoms. In the early stages of chronic
bronchitis, a cough usually occurs in the morning. As the disease progresses,
coughing persists throughout the day. This chronic cough is commonly referred
to as "smoker's cough." Also In the early stages of chronic
bronchitis, only the larger airways are affected, but eventually all airways
are involved. Over time the patient experiences abnormal ventilation-perfusion:
insufficient oxygenation of blood (hypoxemia), labored breathing
(hypoventilation) and right-sided heart failure (cor pulmonale). Compared with
acute bronchitis, which may respond quickly to medications, such as
antibiotics, chronic bronchitis can be difficult to treat because many patients
with chronic bronchitis are susceptible to recurring bacterial
infections. Excessive mucous production in the lungs provides a good
environment for infection, which also causes inflammation and swelling of the
bronchial tubes and a reduction in the amount of airflow in and out of the
lungs. In the later stages of chronic bronchitis, the patient cannot clear this
thick, tenacious mucus, which then causes damage to the hair-like structures
(cilia) that help sweep away fluids and/or particles in the lungs. This in turn
impairs the lung's defense against air-borne irritants. Cigarette smoking is
the most common cause of chronic bronchitis. People who have been exposed for a
long time to irritants, like chemical fumes, dust and other noxious substances,
can also get chronic bronchitis. As chronic bronchitis often coincides
with emphysema, it is frequently difficult for a physician to distinguish
between the two. Chronic bronchitis also can have an asthmatic component. Lying
down at night can worsen the condition, so some people with advanced chronic
bronchitis must sleep sitting up. In late, severe stages people who often have
emphysema as well, are called "blue bloaters" because lack of oxygen
causes the skin to have a blue cast (cyanosis) and because the body is swollen
from fluid accumulation caused by congestive heart failure. There is no cure
for chronic bronchitis. Treatment is aimed at relieving symptoms and preventing
complications. (http://www.copd-international.com/bronchitis.htm,
retrieved 2-18-2009 )
-
Pneumonia is an infection
or inflammation
of the lungs.
It can be in just one part of the lungs, or it can involve many parts.
Pneumonia is caused by bacteria,
viruses,
fungi,
and other microorganisms. The severity of pneumonia depends on which organism
is causing the infection. Viral pneumonias are usually not very serious, but
they can be life-threatening in very old and very young patients, and in people
whose immune
systems are weak. (http://www.emedicinehealth.com/viral_pneumonia/article_em.htm,
retrieved 2-18-2009 )
III.
HISTORY
LEADING TO ADMISSION: Shortness of breath and pain in the left flank area.
IV. THINGS I HAVE TO DO TODAY:
Learning Goal
- Learn how to treat a client with COPD.
Approach
- Review the disease the night before and watch the nurse closely, also
be in the room when the physicians round.
______________________________________________________________________________
V. LABORATORY TESTS:
Test Norms Results Nursing Implications
______________________________________________________________________________
VI. TREATMENTS (i.e., P.T.,
R.T., dressing change):
Treatment
PT eval and treat Both being done to assess the clients
level of functioning with and without oxygen.
OT eval and treat
RT = Albuterol and Atrovent nebulizers Q6 and PRN
RT = 6 minute walk with pulse oximetry for home o2 eval.
- CXR:
LLL infiltrate (indicative of COPD)
- CT
Chest: BL infiltrates (Indicative of COPD)
- Lower
extremity Doppler: negative for DVT
- 2D
Echocardiogram: 55-60% EF
VIII. DIET: Cardiac Stage 3 RESTRICTIONS: low salt
and cholesterol
A. Reason
why on this diet. History of HTN and hyperlipidemia
IX. Surgery: Does not apply
X. CLIENT PROBLEMS/NURSING INTERVENTIONS:
SEE ATTACHED CARE PLAN
MEDICATIONS
MEDICINE
(Brand & Generic) Route, Dose, and
Times
|
CLASSIFICATION
|
ACTION
|
REASON FOR GIVING
|
NURSING INTERVENTION
|
|
Heparin 5000u = 1ml = inj subcut Q8 @0600
|
Anticoagulant, antithrombotic
|
Prevention of thrombus formation and extension of existing thrombi
|
DVT prophylaxis d/t patient not getting up out of bed and ambulating
frequently
|
Hemorrhage, localized pain and redness in injection site,
thrombocytopenia (low platelets).
|
Assess platelet and Hematocrit levels. Protect from injury. Check for
bleeding (stool, urine). Protect patient from injury. Assess injection site.
|
Tylenol (acetaminophen) 650 mg = 2 tabs= PO Q6 PRN pain or fever
|
Antipyretic, analgesic
|
Inhibits the synthesis of prostaglandins that cause the transmission
of pain to the CNS and reduces fever.
|
As needed for mild to moderate pain and fever.
|
Hepatic failure, hepatotoxicity (overdose), may increase the risk of
bleeding of taking warfarin also, rash, urticaria
|
Maximum daily limit is 4 grams. Inform client not to drink alcohol
while taking acetaminophen. Assess pain using COLDSPA. Notify MD of fever.
Check ALT and AST.
|
Tessalon Pearls (benzonate) 100mg = 1 cap PO TID @ 2200
|
Anti-tussive, Non opioid
|
Anesthetizes cough or stretch receptors in vagal nerve afferent
fibers found in lungs, pleura, and respiratory passages.
|
Cough
|
Headache, mild dizziness, sedation, burning eyes, nasal congestion,
constipation, stomach upset, nausea, pruritis, skin eruptions, chest
numbness, chilly sensation, hypersensitivity reaction.
|
Change positions slowly, assess for bowel sounds and ask about BM,
assess lung sounds, assess respirations, adives patient to avoid irritants
such as smoking, encourage high fowlers position
|
Voltaren (diclofenac) 75mg = 1 tab PO BIDBS @ 0800 w/meal
|
NSAID, Nonopioid analgesic
|
Inhibits prostaglandin synthesis, anti inflammatory
|
Decrease inflammation in the respiratory system
|
Dizziness, headache, drowsiness, tachycardia, HTN, hypotension,
tinnitus, muscle weakness, N&V, flatulence, cramps, dry mouth, GI bleed,
dysuria, UTI, epistaxis, bruising
|
Change positions slowly, instruct patient not to operate machinery
while taking medication, assess stool for heme or tarry blackness, check CBC
|
Mucinex (guaifenesin) 600mg = 1 tab
|
Expectorant
|
Increase the volume and reduces the viscosity of secretions in the
trachea and bronchi to facilitate secretion removal
|
Productive and nonproductive cough
|
Drowsiness, headache, dizziness, N&V
|
Change positions slowly, increase fluid intake, do not break, crush,
or chew tablet, evaluate cough and sputum and assess lung sounds
|
Levaquin (levoflaxin) 500mg = 1 tab
|
antiinfective
|
Interferes with conversion of DNA in bacteria
|
bronchitis
|
Headache, dizziness, insomnia, anxiety, seizures, encephalopathy,
chest pain, palpitations, vasodilation, dry mouth, visual impairment,
N&V, flatulence, abdominal pain, vaginitis, crystalluria, hemolytic
anemia, rash, pruritis, hypoglycemia,
|
Change positions slowly, check CBC, assess WBC count, assess bowel
pattern daily, assess cogniscence, check BP q4, encourage fluids, check blood
sugar, check sodium level
|
Robaxin (methocarbamol) 500mg = 2 tabs= 1000mg
|
Muscle relaxant
|
Depresses multisynaptic pathways in the spinal cord, causing skeletal
muscle relaxation
|
bronchospasm
|
Dizziness, weakness, drowsiness, depression, seizure, postural
hypotension, blurred vision, N&V, discolored urine, rash, pruritis,
fever, hepatitis
|
Change position slowly, check sodium level, instruct patient not to
operate machinery while taking this medication, assess urine, assess skin,
assess CBC, check AST and ALT
|
Nicoderm (nicotine transdermal) 1 patch daily @1300
|
Smoking deterrent
|
Agonist at nicotine receptors in peripheral, CNS.
|
Deter cigarette smoking
|
Dizziness, vertigo, insomnia, headache, confusion, seizures,
depression, numbness, tinnitus, dysrhythmias, edema, HTN, N&V, diarrhea,
abdominal pain, constipation, breathing difficulty
|
Change position slowly, assess sleep patterns, assess cognition,
auscultate heart sounds, assess for edema, assess abdomen and bowel sounds,
check BM, auscultate lungs, instruct patient not smoke while using patch for
24 hours even if patch removed, check BP
|
Protonix
(pantoprazole) 40mg
|
proton pump inhibitors
|
Binds to an enzyme in the presence of gastric acid, preventing
hydrogen ions going into the stomach
|
Decrease symptoms of heartburn and stomach upset
|
Headache, insomnia, diarrhea, abdominal pain, rash, hyperglycemia
|
Assess bowel sounds and abdomen, check BM, assess sleep pattern and
skin, check blood glucose
|
Prednisone (methylpredisolone) 30mg = 3 tabs
|
Corticosteroid
|
Decreases inflammation
|
Inflammation in the respiratory system
|
Depression, flushing, sweating, headache, mood changes, HTN,
thrombophlebitis, blurred vision, nausea, pancreatitis, thrombocytopenia,
immunocompromisation, hypokalemia, hyperglycemia
|
Check blood glucose, check platelets, check WBC count, assess stool
for heme or tarry blackness, do vital signs, check potassium, assess for
edema, I&O ratio
|
Lab
|
Range
|
Admit
Result
|
Current
Result
|
Clinical
Day
|
NURSING IMPLICATIONS
|
WBC's
|
4.5-11.0 cells/mcL
|
5.0
|
4.6
|
3.3
|
|
4.6-6.0 cells/mcL
|
4.4
|
4.5
|
4.31
|
Assess for
fatigue, palpitations, chest pain, SOB on exertion, and tachypnea. Check MM’s
and skin color. Assess diet and look for signs of bleeding.
|
|
Hgb
|
12.6-17.4 gm/dL
|
13.5
|
13.2
|
13.3
|
|
Hct
|
43-49% (percentage
of red blood cells)
|
39.1
|
38.7
|
38.3
|
Assess for
fatigue, palpitations, chest pain, SOB on exertion, and tachypnea. Check MM’s
and skin color. Assess diet and look for signs of bleeding.
|
Platelets
|
150-450 mm3
|
269
|
258
|
244
|
|
Glucose
|
65-99 mg/dL
|
144
|
215
|
Assess diet.
Assess for increased thirst, urination, fatigue, blurred vision, and slow
healing infections. Assess medications and IV fluids: corticosteroids, tricyclic antidepressants, diuretics, Protonix,
epinephrine, estrogens (birth control pills and hormone replacement),
lithium, phenytoin (Dilantin), salicylates, can cause high blood glucose.
|
|
Potassium
|
3.5-5.0 mEq/L
|
4.1
|
4.0
|
n/a
|
|
Sodium
|
135-145 mEq/L
|
141
|
138
|
n/a
|
|
Calcium
|
8.2-10.2 mg/dL
|
9.2
|
n/a
|
n/a
|
|
Chloride
|
97-107 mEq/L
|
102
|
102
|
n/a
|
Assess for dehydration (dry MMs, dry eyes, N&V or
diarrhea), diuretics, corticosteroids, and laxatives may cause hypochloremia.
Watch for muscle twitching, irritability, increased urination, poor appetite,
sleepiness, or confusion.
|
BUN
|
8-21 mg/dL
|
9
|
20
|
n/a
|
|
Creatnine
|
0.6-1.2 mg/dL
|
0.8
|
0.8
|
n/a
|
|
CK
|
26-140 U/L
|
29
|
n/a
|
n/a
|
|
Phosphorus
|
2.5-4.5 mg/dl
|
2.7
|
8.3
|
n/a
|
Assess renal
function, check blood gases, check for PE, assess respirations, assess
urination
|
Magnesium
|
1.6-2.1 mg/dl
|
2.1
|
1.9
|
n/a
|
|
Co2
|
22-26 mmol/L
|
32
|
28
|
n/a
|
Check pulse ox,
assess cap refill, assess for cyanosis on mouth, face, and extremities, sit
patient in high Fowler’s position, administer oxygen if applicable, minimize
exertion, encourage deep breathing
|
BNPP
|
< 100 pg/ml
|
558
|
n/a
|
n/a
|
Assist in
differentiation of heart failure vs. pulmonary disease, assist patient to
high fowlers position when applicable
|
XI.
PATIENT FOCUS ASSESSMENT
|
ABNORMAL
|
|
General Survey
|
48 yr old female, hair is evenly dispersed throughout body
according to sex, hair is lustrous, appears to be well nourished, no signs of
dehydration or cachexia, affect is appropriate, speech is clear.
Vital signs: BP 152/88, TEMP 97.3, sao2 96 on 4 liters of
o2, HR 80, pain level is a 7 on a scale of 1-10 in the left flank.
|
Lacking in proper hygiene a.e.b. dried crust behind and
inside external ear, between breasts, declined bathing assistance, states she
“wants to do it at home.”
|
Head
|
Head is proportionately sized, face is symmetrical, smile
is even, hair is evenly disbursed. Conjunctivae are pink and moist, oral
mucosa is pink and moist, gums are pink, tongue is midline, throat is visibly
clear and pink.
|
|
Eyes
|
Eyes are even and symmetrical, pupils are equal, round, reactive and accommodating to light,
no crust or exudates, lashes are intact and full, eyebrows are intact and
full
|
|
Ears
|
Ears are even and symmetrical, no drainage or c/o pain.
Responds to whisper.
|
External and behind the ear crust is present, indicative
of subpar hygiene.
|
Nose and Sinuses
|
Nose is midline, septum is intact, no drainage or crust,
sinuses nontender on palpation
|
|
Neck and Pharynx
|
Negative for JVD, trachea is midline, full ROM of neck. Voice
is non strained and clear. No carotid bruits.
|
|
Thorax and Lungs
|
Chest rises and falls symmetrically. No scars, marks, or
striae, no visible pulsations.
|
Wheezes and Rhonchi auscultated in BL lower lobes and R
middle lobe, non-productive cough, labored, shallow breathing without use of
accessory muscles. Pain around the sixth intercostal space that radiates to
the left lower back that is r/t COPD and bronchitis, worsens on deep
inspiration.
|
Cardiovascular
|
S1 and S2 auscultated no gallops, rubs, or thrills. Apical
pulse palpated at 5th intercostal space. No visible pulsations on
precordium. Normal sinus rhythm on the monitor with no ectopy.
|
|
Gastro-Intestinal and Abdomen
|
Abdomen is round, soft, non-tender, no scars, marks, or
striae, no visible pulsations or hernias, umbilicus is midline and inverted.
Last BM was
|
|
Urinary
|
Urinates every 3 to 5 hours, pale yellow, no c/o burning
or stinging, no frequency or urgency.
|
|
Neurological/Cranial Nerves/Sensory
|
A&O X3, speech is clear and appropriate, sensation
intact without numbness,
|
|
Motor/Musculoskeletal
|
Functional ROM on all limbs, +5 strength bilaterally,
dorsiflexion and plantar flexion present and appropriate for patient.
|
|
Skin
|
Skin warm, dry, intact. No acute surgical incisions, areas
of redness or breakdown.
|
Dry crusty areas between breasts, in external ears, and
behind ears. There are two blisters on the left index and middle finger. Skin
color sallow.
|
Peripheral Vascular
|
Capillary refill less than 3 seconds on extremities.
Bilateral pulses on extremities are regular, rhythmic, and +2 strength.
|
|
Dressings
|
Not applicable
|
|
Drainage Tubes
|
Not applicable
|
|
IV Sites
|
Right AC, dated
|
XII.
a)
Psychosocial State
b)
Subjective
Concerns & Statements: “I know that this isn’t going to go away. I want to
quit smoking but I just can’t. I don’t know what to do. I give up.”
c)
Psychosocial
Adjustment to Illness: She states that
she smokes when she’s under stress, which in turn, stresses her out
additionally.
d)
Cultural/Spiritual
Needs and Concerns: Doesn’t go to church. She has no concerns about going.
e) Patient Education Needs: Smoking cessation. I
suggested it to her nurse, we’ll see if a cardiac rehab consult gets
implemented. She does agree not to go outside and smoke while she is a patient,
and uses Nicoderm patches.
ASSESSMENT
|
NURSING DIAGNOSIS
|
PLANNING
|
NURSING
IMPLEMENTATION
|
EVALUATION
§ Goals
§ Evaluations
|
S: “I
couldn’t catch my breath and my chest hurt really bad.”
O: X-ray
showing bilateral infiltrates.
O: Co2
level was elevated @ 32 upon admission.
O: Expiratory
and inspiratory high and low pitched wheezes and rhonchi auscultated in BL LL
and RML.
O: Pulse ox
on admission was 90% on room air.
|
Ineffective airway clearance r/t bronchoconstriction, increased mucus,
ineffective cough, and infection secondary to bronchitis and COPD a.e.b.
client statement of SOB, radiographic testing, and nursing assessment.
Scientific Rationale:
- Chronic obstructive
pulmonary disease (COPD) is the overall term for a group of chronic lung
conditions that obstruct the airways in your lungs. COPD usually refers to
obstruction caused by chronic bronchitis and emphysema, but it can also refer
to damage caused by asthmatic bronchitis. In all forms of COPD, there's a
blockage within the tubes and air sacs that make up your lungs, which hinders
your ability to exhale.
(http://www.mayoclinic.com/health/copd/DS00916,
retrieved
- Chronic bronchitis is an
inflammation of the main air passages (bronchi) to the lungs, which results
in the production of excess mucous,
a reduction in the amount of airflow in and out of the lungs and shortness of breath. In chronic
bronchitis, there is excessive bronchial mucus with a productive cough for
three months or more over two consecutive years without any other disease
that could account for these symptoms. (http://www.copd-international.com/bronchitis.htm,
retrieved
|
STG: The
client will demonstrate proper use of the incentive spirometer by doing
hourly repetitions correctly by the end of the shift.
LTG: The
client will maintain sao2 level above 91% while hospitalized.
1.
Monitor skin color and temperature and level of consciousness q4 during vital
signs.
*
Cyanosis, cool clammy skin, and changes
in LOC (agitation, lethargy, or confusion) indicate worsening hypoxia. (LeMone,
2008 p.1329)
2.
Assess pulse oximetry readings q4 during vital signs; notify the nurse of
abnormal values or changes in status.
* This value provides information
about gas exchange and the adequacy of alveolar ventilation. A fall in oxygen
saturation levels is an early indicator of impaired gas exchange. (LeMone, 2008 p.1329
3. Place in Fowler’s or
high-Fowler’s position to facilitate breathing and lung expansion.
* These positions reduce the work of breathing and increase lung
expansion, especially basilar areas. (LeMone, 2008 p.1329)
4. Increase fluid intake.
* Increasing fluids helps keep secretions thin. (LeMone, 2008
p.1329)
5. Administer oxygen as
ordered.
* Supplemental oxygen reduces hypoxemia. (LeMone, 2008 p.1329)
|
1. Monitored skin color and
LOC q4 during each set of vital signs.
2. Assessed pulse ox during
q4 vitals.
3. Asked patient to sit up
in Fowler’s position.
4. Filled client’s water
pitcher with fresh water every twice during shift.
5. Patient on 4L per NC as
ordered by MD.
|
STG: Goal
not met. The client demonstrated proper use of the incentive spirometer, but
did not use on an hourly basis, even with encouragement. She said that it
made her lightheaded. Reported to the nurse.
LTG:
Unable to assess.
1. Skin color sallow,
temperature 97.6 and 97.4, no change in LOC.
2. Pulse ox readings were
96% and 97% on 4L per NC.
3. Patient sat up in
Fowler’s position for an hour.
4. Patient’s fluid intake
during shift was 1595ml. (Urinated 3 times during shift)
5. Patient kept NC on
except for bathroom trips. (Pulse ox when returned 4 minute bathroom trip was
91%)
|
ASSESSMENT
|
NURSING DIAGNOSIS
|
PLANNING
|
NURSING
IMPLEMENTATION
|
EVALUATION
§ Goals
§ Evaluations
|
S: “It
gets harder to breathe when I move around too fast.”
S:”I’m
just so tired lately.”
S: “I’m
too tired to eat and I don’t like the food.”
O: CXR
showed bilateral infiltrates indicative of COPD and bronchitis.
O: Co2
level elevated on admission @32.
O: Pulse
ox on admission was 90% on room air.
|
Risk for imbalanced nutrition: less than body requirements r/t fatigue and dyspnea caused from physical
exertion of eating.
Scientific Rationale: The client with COPD fatigues easily; adequate rest
is important to conserve energy and reduce fatigue. With advanced COPD,
minimal activity, including eating, can cause fatigue and dyspnea. The client
may be unable to consume a full meal without resting. Increased work of
breathing also increases metabolic demands. (LeMone, 2008 p. 1339)
|
STG: The client will state her usual nutritional intake after vital signs.
LTG: A dietary consult will be implemented by nursing to assess and educate
the clients eating habits during hospitalization.
1.
Assess nutritional status, including diet history and any weight fluctuations
and appetite.
*
It is important to differentiate
nutritional status from body type rather than assume a nutritional
impairment. (LeMone, 2008 p. 1339)
2.
Suggest a dietary consult to plan meals and nutritional supplements as well
as easy menu ideas for home.
*
More concentrated sources of high
energy foods may be requires to maintain caloric intake without excess
fatigue. A diet high in proteins and fat without excess carbs is recommended
to minimize carbon dioxide production during metabolism. (LeMone, 2009 p.
1339)
3.
Provide frequent, small snacks in between meals.
* Frequent small meals help maintain intake
and reduce fatigue associated with eating.(LeMone, 2008 p. 1339)
4.
Place in seated or high-Fowler’s position for meals.
* An upright seated position promotes
lung expansion and reduces dyspnea.(LeMone,
2008 p. 1339)
5.
Encourage choosing her own food by placing order with the kitchen instead of
getting whatever the kitchen sends.
* Providing preferred foods promotes
eating more. (LeMone, 2008 p. 1339)
|
1. Asked about usual
nutritional intake and if she has had any weight fluctuations recently.
2. Suggested a dietary
consult to the nurse after showing her the client’s uneaten breakfast tray.
3. Followed the professor’s
lead and gave her a couple of packets of graham crackers with jelly to snack
on throughout the day.
4. Suggested going to the
chair for meals, but she wanted to stay in bed. I sat her up in Fowler’s
position.
5. Gave her a menu and the
number to the kitchen so that she could order something that she liked.
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STG: The
client stated that while in the hospital, she eats about ¼ of her tray, but
eats 3 to 4 patient ice creams a day.
LTG: Suggested
a dietary consult, and the nurse acknowledged that the client does not eat
enough. Did not indicate whether or not she would implement the consult.
1. The client denied any
weight loss or gain in the past six months, but did say that her appetite has
decreased. She doesn’t eat “very much.”
2. The nurse agreed that
the client didn’t eat enough, but did not indicate that she would order a
dietary consult.
3. The client was
appreciative and did snack on the crackers every hour.
4. Sat in Fowler’s position
to eat but immediately wanted to take a nap after.
5. She looked over the menu
and declined the opportunity to order for herself. I offered to order for her
and she said that she hates the foods all the same. I brought her an ice
cream.
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ASSESSMENT
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NURSING DIAGNOSIS
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PLANNING
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NURSING
IMPLEMENTATION
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EVALUATION
§ Goals
§ Implementations
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S: “I know
I have to quit soon.”
S: “I’m
ashamed that I didn’t quit before.”
O: Facial
expression sad, looking at the wall, holding back tears.
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Decisional Conflict with smoking r/t medical and nursing advice to quit
smoking to improve health status.
Scientific Rationale:
- Smoking is more than a
habit, it’s an addiction. The client who must quit is facing a significant
loss, not only of nicotine, but of a lifestyle. Although the client may fully
comprehend the consequence of continuing to smoke, the decisions to give into
that part of his or her life is not easy. (LeMone, 2008 p. 1340)
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STG: The
client will at least verbally acknowledge the effects of continuing to smoke
against medical advice during the shift.
LTG: The
client will not smoke during hospitalization.
1. Assess knowledge and
understanding of the choices involved and possible consequences of each.
* The decision to quit smoking ultimately belongs to the client. He or
she needs a full understanding of the consequences of quitting or continuing
to smoke. (LeMone, 2008 p. 1340)
2. Acknowledge concerns,
values, and beliefs; listen nonjudgmentally.
* The nurse needs to avoid imposing his or her values and beliefs about
smoking on the client. (LeMone, 2008 p. 1340)
3. Spend time with the
client, encourage expression of feelings.
* This demonstrates acceptance of the client and his or her right to
make the decision. (LeMone, 2009 p.1340)
4. Offer to help plan a
course of action for quitting smoking collaboratively with the patient.
* When the client develops the plan, he or she has more ownership in it
and interest in making it work. (LeMone, 2008 p. 1340)
5. Demonstrate the right
for decisions and the right to choose.
* Respect supports self-esteem and the ability to cope. (LeMone, 2008 p. 1340)
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1. Asked the client is she
understood her options of quitting or not.
2. Let the patient speak
about her reasoning for smoking with a nonjudgmental attitude.
3. I asked the client if
she thought she was strong enough now to quit.
4. Offered to have the
nurse request a cardiac rehab consult which educated clients on smoking
cessation and gives them a lot of information about support groups, etc.
5. Did not show any
disappointment or disagreement.
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STG: Goal
met. The client stated that she is aware of the risks of continuing to smoke
and she wants to quit but can’t.
LTG: Unable
to assess, however, patient was compliant with orders not the leave the unit
d/t being on telemetry and did allow nicotine patches to be administered.
1. She stated that she
understood that her condition will never get better, but she will be able to
keep it under control if she quits now.
2. She gave excuses as to
why she hasn’t quit yet: marital problems, parent’s illness, money stress. I
explained that I quit after 10years of smoking, so I understood how difficult
it can be.
3. She said that she thinks
so once she gets her husband out of the house.
4. She declined the offer.
5. I explained that I knew
she will quit when she is ready. We all need our own time to make the choice.
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