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Goal: Pt will maintain patent airway, demonstrating effective breath sounds and the ability to cough and clear secretions.

Nursing diagnosis: Risk for ineffective airway clearance r/t increased mucous production and coughing.

Interventions:

1. Assess the airway for patnecy by listening to the client's breathing, observing the client's chest and neck movements.

2. Auscultate lungs for presensce of abnormal sounds (wheezing, decreased or absent breath sounds, crackles) as it could indicate the presence of an obstruction.

3. Note presnece of sputum; evaluate quality, color, amount, odor and consistency as it could indicate a sign of infection.

4. Note cough and factors ; an ineffectice cough compromises airway clearance and prevent mucus from leaving.

5. Note for changes in HR,BP and temperature; increased WOB may lead to tachycardia; changes in vital signs may also indicate ineffective airway clearance.

6. Educate pt on leaving the hob to 30 degrees, use of abdominal muscles to lead to a more useful cough, importance of ambulation.

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Goal: Pt will demonstrate understanding of safety measures to prevent falls.

Nursing diagnoses: Risk for falls aeb weakness to extremeties, R parietal stroke, hx of falls and decreased sensory perception.

Interventions:

1. Educate the patient on fall prevention strategies: Teach the patient about the importance of using assistive devices (like a walker or cane) and maintaining a clutter-free environment to reduce trip hazards. Reinforce the need to avoid walking in unfamiliar or poorly lit areas.

2. Assess the environment for safety hazards: Ensure the patient’s living space is free from obstacles (loose rugs, cords).

3. Encourage strength and balance exercises: Work with the physical therapist to develop a plan that includes exercises to strengthen the extremities and improve balance, such as seated leg lifts or gentle walking exercises.

4. Monitor vital signs and cognitive status regularly: Keep track of blood pressure, heart rate, and cognitive changes to identify any factors that may contribute to falls, such as orthostatic hypotension or confusion.

5. Assist with mobility and positioning: Help the patient with standing, sitting, and transferring to ensure safe movement. Ensure the patient is never left unattended during transfers and that they can call for help if needed.

6. Review medications with the healthcare provider: Assess the medications the patient is taking to determine if any contribute to dizziness or weakness.

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Goal: Pt will describe a satisfactory pain control at a level of less than 4 on a rating of 0-10.

Nursing diagnosis: Acute pain r/t to tissue injury from surgical incision aeb patient reporting a pain level of 7 on a 1-10 scale.

Interventions:

1. Assess pain regularly: Monitor the patient's pain level using a standardized pain scale (e.g., 0-10) every 2 hours or as needed to evaluate the effectiveness of pain management interventions.

2. Administer prescribed pain medication: Provide pain medications as ordered, ensuring the patient receives the appropriate dosage, and adjust based on their pain level and response. Use both analgesics (e.g., opioids or non-opioid medications) and adjunct therapies as needed.

3. Encourage non-pharmacological pain relief techniques: Teach and encourage the patient to use relaxation techniques (e.g., deep breathing, guided imagery, or music therapy) to help manage pain and reduce anxiety.

4. Position for comfort: Ensure the patient is positioned in a way that minimizes strain on the surgical site, offering pillows or supports to promote comfort and reduce pain.

5. Provide ice or heat therapy (if appropriate): Apply ice or heat to the surgical area (as per the physician's order) to reduce inflammation and alleviate pain.

6. Educate the patient about pain management options: Teach the patient about their pain management plan, including the expected time frame for pain relief and the importance of communicating any changes in pain levels. Empower the patient to ask for assistance before the pain becomes severe.

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Goal: The patient will remain free from infection aeb absence of signs of infection (redness, warmth, swelling, discharge).

Nursing diagnosis: Risk for infection aeb compromised skin integrity due to incisions at thoracentesis site.

Interventions:

1. Monitor the thoracentesis site for signs of infection (redness, warmth, swelling, discharge) at regular intervals; along with vital signsReport any changes immediately.

2. Keep the thoracentesis site clean and dry by following proper wound care protocols. Use sterile techniques when dressing the wound, and change the dressing as prescribed or when it becomes wet or soiled.

3. Encourage proper hand hygiene for both the patient and caregivers before touching the thoracentesis site or dressing to prevent the introduction of pathogens.

4. Assess the patient's temperature regularly to detect any early signs of infection (36.5-37.5 degrees). A rise in temperature could indicate the onset of an infection.

5. Educate the patient and family about the importance of avoiding unnecessary movement or trauma to the thoracentesis site, as this could compromise the healing process and increase infection risk.

6. Promote adequate nutrition and hydration to support immune function and tissue healing, as a well-nourished body is better able to fight off infections.

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Goal: The patient will demonstrate knowledge of insulin injection techniques, recognize symptoms and appropriate treatment of hypo/hyperglycemia and exhibit understanding of dietary requirements for managing their condition.

Nursing diagnosis: Risk for distrubed sensory perception aeb reports of blurred vision.

Interventions:

1. Educate the patient on insulin injection techniques: Teach the patient how to correctly administer insulin, including the proper sites for injection, rotation of injection sites, and the importance of proper technique to avoid complications such as lipohypertrophy.

2. Provide instruction on recognizing hypo- and hyperglycemia symptoms: Educate the patient on the common signs of low and high blood sugar (e.g., shakiness, dizziness, confusion, excessive thirst) and how to treat each condition appropriately (e.g., consuming fast-acting carbohydrates for hypoglycemia and administering extra insulin or fluids for hyperglycemia).

3. Discuss dietary requirements for managing blood glucose: Teach the patient about the importance of consistent carbohydrate intake, meal timing, and balancing foods for better blood sugar control. Include the role of fiber, protein, and fat in managing blood sugar levels.

4. Monitor and assess visual changes: Regularly assess the patient for changes in vision (blurred vision) and report any worsening symptoms to the healthcare provider to evaluate potential complications related to diabetes (e.g., diabetic retinopathy).

5. Collaborate with the healthcare team for a personalized treatment plan: Work with the dietitian and to create an individualized meal plan and insulin regimen, ensuring the patient understands how their specific needs can be met.

6. Encourage frequent blood sugar monitoring: Teach the patient how to monitor their blood sugar regularly and how to interpret results. Provide guidance on when to contact a healthcare provider if levels are consistently out of range, especially in relation to vision changes.

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Goal: Patient will be able to verbalize/vent present ideas of how to handle these feelings of anxiety related to falls.

Nursing diagnosis: Anciety r/t recent falls aeb verbalization of feelings of anxiety.

Interventions:

1. Establish a trusting relationship: Build rapport with the patient by actively listening, showing empathy, and creating a safe environment where the patient feels comfortable expressing their feelings.

2. Provide education on fall prevention: Educate the patient on strategies to prevent future falls, including exercises to improve balance, use of assistive devices, and environmental modifications, which can reduce anxiety by offering a sense of control.

3. Encourage relaxation techniques: Teach and guide the patient in relaxation methods, such as deep breathing exercises, progressive muscle relaxation, or guided imagery, to help reduce anxiety and stress related to falls.

4. Explore coping mechanisms: Engage the patient in identifying healthy coping strategies (e.g., mindfulness, journaling, or speaking with a support person) that can help her manage her anxiety about falling.

5. Monitor and assess anxiety levels: Regularly assess the patient’s anxiety level using a standardized scale and provide feedback on progress. This helps to evaluate the effectiveness of interventions and identify the need for adjustments.

6. Offer emotional support: Provide reassurance and validate the patient’s feelings by acknowledging their fears and concerns. Let the patient know they are not alone and that their feelings are normal given the situation.

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68 year old female

Admitted on March 1, 2025

Admitting dx: Fall at home, stroke symptoms upon EMS arrival

Medical hx: COPD, HTN, T2DM, OSA, malignant pleural effusion, asthma, lung cancer

Surgical hx: shoulder repair, breats tumor removal, throacentesis

Psychosocial: anxiety, husband at bedisde, active smoker for 50 years

Allergies: NKDA

Code status: R1

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1. Acetylsalicylic Acid (Aspirin) - 81 mg (1 tab)

Usage:

Antiplatelet medication used to prevent thromboembolic events, such as stroke or heart attacks, particularly in patients with cardiovascular risk factors.

Monitoring:

Monitor for signs of bleeding (e.g., bruising, hematemesis, melena).

Check renal function and liver enzymes periodically (especially with long-term use).

Hemoglobin/hematocrit to assess for anemia or GI bleeding.

Monitor tinnitus if patient experiences symptoms.

2. Clopidogrel Bisulfate (Plavix) - 75 mg (1 tab)

Usage:

Antiplatelet agent used for stroke prevention, acute coronary syndrome, and prevention of cardiovascular events in high-risk patients (e.g., post-stroke, post-myocardial infarction).

Monitoring:

Monitor platelet count regularly, especially in patients with signs of bleeding.

Periodically assess liver function tests (LFTs).

Watch for signs of GI bleeding (e.g., hematemesis, melena).

Hemoglobin/hematocrit levels to detect bleeding.

3. Tinzaparin (LMWH) - 4500 units (subQ)

Usage:

Anticoagulant used for DVT prophylaxis, treatment of deep vein thrombosis (DVT), or pulmonary embolism (PE), particularly post-surgery or in patients with limited mobility.

Monitoring:

Monitor platelet count for thrombocytopenia.

Check for signs of bleeding (e.g., bruising, hematoma, melena).

Periodic renal function tests (due to potential renal clearance of LMWH).

Anti-factor Xa levels may be monitored for high-risk patients, especially if renal function is impaired.

4. Insulin (Correction Insulin)

Usage:

Insulin therapy for the correction of high blood glucose in diabetic patients, particularly in patients with hyperglycemia or poorly controlled blood sugar levels.

Monitoring:

Regular blood glucose monitoring (fasting, pre-meal, post-meal, or as needed).

Monitor for signs of hypoglycemia (shakiness, sweating, confusion, dizziness).

Hemoglobin A1c to assess long-term blood sugar control.

5. Amoxicillin - 1 tab (PO) BID until March 7

Usage:

Antibiotic in the penicillin class, used for the treatment of bacterial infections such as respiratory tract infections, urinary tract infections, or skin infections.

Monitoring:

Renal function in patients with preexisting renal impairment.

Watch for signs of allergic reaction (e.g., rash, anaphylaxis).

Monitor for GI side effects (diarrhea, nausea).

If prolonged use, monitor for superinfection or liver enzymes.

6. Tiotropium - 2 inhalations once daily (at bedtime)

Usage:

Long-acting muscarinic antagonist (LAMA) used for the maintenance treatment of COPD and asthma to improve airflow and reduce bronchospasm.

Monitoring:

Lung function (e.g., PEF or spirometry).

Watch for dry mouth or urinary retention.

Signs of anticholinergic toxicity, such as confusion, dizziness, and blurred vision.

7. Amlodipine - 5 mg (1 tab)

Usage:

Calcium channel blocker is used for managing hypertension and angina by relaxing blood vessels and reducing heart workload.

Monitoring:

Monitor for blood pressure regularly.

Assess for edema or signs of fluid retention.

Heart rate (if signs of bradycardia or palpitations).

Liver function tests (if any signs of liver issues).

8. Ramipril - 5 mg (1 tab)

Usage:

ACE inhibitor used for hypertension, heart failure, stroke prevention, and diabetic nephropathy.

Monitoring:

Blood pressure to assess for hypotension.

Serum potassium (to avoid hyperkalemia).

Renal function (creatinine and GFR).

Signs of angioedema (swelling of the face, lips, tongue).

9. Gabapentin - 600 mg (1 tab)

Usage:

Anticonvulsant used for neuropathic pain (e.g., diabetic neuropathy) and seizures.

Monitoring:

Assess for sedation or dizziness when starting the medication.

Watch for edema or weight gain.

Monitor for signs of abuse in patients with a history of substance use disorder.

10. Fluticasone (Inhaled) - 2 puffs twice daily

Usage:

Inhaled corticosteroid for reducing inflammation in the airways in conditions like asthma and COPD.

Monitoring:

Rinse mouth after use to prevent oral thrush.

Monitor for signs of fungal infection in the mouth.

Check for signs of adrenal suppression or osteoporosis with long-term use.

11. Metformin - 500 mg (1 tab)

Usage:

Biguanide for managing type 2 diabetes mellitus by improving insulin sensitivity and decreasing hepatic glucose production.

Monitoring:

Renal function (creatinine and eGFR) to prevent lactic acidosis.

Blood glucose levels to monitor diabetes control.

Vitamin B12 levels if long-term use is required.

# data[].attributes.body
WBC H 13.35 (4.10-9.90)

MCHC H 347 (308-344)

Neutrophils H 9.88 (1.80-8.00)

Monocytes H 0.97 (0.30-0.70)

Eosinophils 0.68 (0.00-0.30)

Immature grannulocyte H 0.26 (0.00-0.10)

Chloride L 00 (100-110)

Ck l 23 (30-200)

Glucose fasting H 9.2 (3.6-6.0)

HA1C H 6.8% (4.5-6.5%)

# data[].attributes.body
Chronic Obstructive Pulmonary Disease (COPD):

A progressive lung disease characterized by airflow obstruction and difficulty breathing, often caused by long-term smoking or exposure to irritants.

Symptoms: Shortness of breath, chronic cough, sputum production, wheezing, fatigue, and frequent respiratory infections.

Hypertension (HTN):

A condition where blood pressure is consistently higher than normal, putting strain on the heart and blood vessels.

Symptoms: Often asymptomatic, but can cause headaches, dizziness, shortness of breath, chest pain, and vision changes in severe cases.

Obstructive Sleep Apnea (OSA):

A sleep disorder where the airway becomes blocked during sleep, leading to repeated breathing interruptions.

Symptoms: Loud snoring, choking or gasping for air during sleep, excessive daytime sleepiness, difficulty concentrating, and irritability.

Malignant Pleural Effusion:

A buildup of fluid in the pleural cavity due to cancer (often lung cancer or metastatic cancer).

Symptoms: Shortness of breath, chest pain, cough, and difficulty breathing, especially when lying down.

Asthma:

A chronic inflammatory disease of the airways that causes episodes of wheezing, breathlessness, and coughing due to airway constriction.

Symptoms: Wheezing, shortness of breath, chest tightness, coughing (especially at night or early morning), and increased mucus production.

Lung Cancer:

A type of cancer that begins in the lungs and can spread to other parts of the body.

Symptoms: Persistent cough, chest pain, shortness of breath, hemoptysis (coughing up blood), fatigue, weight loss, and hoarseness.

Thoracentesis:

A medical procedure to remove fluid or air from the pleural space using a needle, usually to relieve symptoms or for diagnostic purposes.

Symptoms: It’s a procedure, not a disease, so symptoms depend on the condition being treated (e.g., pleural effusion causes shortness of breath or chest pain).

Right Parietal Stroke:

A type of stroke affecting the right side of the parietal lobe, which is responsible for sensory processing, spatial awareness, and motor coordination.

Symptoms: Hemineglect (neglecting the left side of the body or environment), difficulty with spatial tasks, sensory loss on the left side of the body, and apraxia (difficulty with purposeful movement).

# data[].attributes.body
Vitals on research day:

BP 112/62, P 87, RR 18, T 36.8, SaO2 92%

CNS: LOCX3, pain at backside, X4 movement and sensation (mn and m), GCS 15/15, left arm drift

CVS: flushed skin, s1 and s2

Resp: 2L NP, audible crackles, frequent coughing, puffer at bedside

Integ: L arm scraped, right posterior bruise at thoracentesis site, tegaderm draining serous, 2 sutures at the incision site

GI: soft distended abdomen, normal bs, last bm march 2

GU: low urine output, foley catheter

MSK: mobility with wheeled walker, normal mod strength on all extremeties

EENT: glasses, moist mucous membranes