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1.) Impaired Dentition r/t difficulty accessing dental care and habitual use of illicit drugs as evidenced by dental caries and mandibular abscess.
2.) Risk-prone health behavior r/t substance abuse and smoking as evidenced by methamphetamines, amphetamines and tetrahydrocannabinol found in a previous drug screen. As well as smoking a pack of cigarettes each day.
Patient goal: Learn how to take advantage of accessing dental care through government programs that will aid with uninsured individuals. The patient will know how to take care of his mouth to prevent infection before discharge. Lastly understanding the implications of the drugs he has previously abused and the effects smoking has on his health.
Patient teaching r/t goal: Providing the patient with information about government programs that will help him to access dental care. Teaching the patient about what amphetamines especially methamphetamines and tetrahydrocannabinol will do to his health and life. Giving the patient pamphlets of information about making health changes related to quitting smoking. And explaining how smoking will change his health and life. Teaching the patient about how his condition could get worse if he doesn't take the steps to reduce infection.

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Potential Complication 1:
Osteomyelitis- An infection of the bone. It is caused by the bacteria in a dental abscess spreading through the bloodstream. Eliminating infection in the patient's mandible before it turns into osteomyelitis. Once the lab cultures and tests identify the cause of infection it will be easier to eliminate it. Nursing interventions include making sure the patient keeps the wounds in his mouth clean and assessing for further signs of infection. In addition teaching the patient the implications of drug use on dental care and infection.
Potential Complication 2:
Ludwig's Angina- A serious and potentially fatal infection in the bottom of the mouth. This can occur if the bacteria from the dental abscess spreads. It causes pain in the mouth and neck. In severe cases it can obstruct breathing. Nursing interventions include monitoring the patient for pain in the neck and abnormally bad pain in the mouth. Watching the patient's respirations and oxygen saturation for changes in status.

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Droperidol (Inapsine)- 0.625mg IV Q6H

Intended effect for patient: Used to reduce nausea and vomiting after surgery.
Patient education: This medication causes confusion, dizziness, sweating and unusual sweating as side effects. It can also cause effects on your heart rhythm. Report to a healthcare professional immediately if you feel like you have chest pain, fast heartbeat, signs of an allergic reaction, tightness of chest or trouble breathing. These signs could mean a medical emergency.

Naloxone (Narcan)- 0.2mg IM injection
Intended effect for patient: Reversal of CNS depression and respiratory depression because of suspected opioid overdose. Patient education: Explain purpose and use of injection to patient. Continue monitoring patient after and alert emergency medical assistance.

Ondansetron (Zofran)- 4mg (PF) injection
Intended effect for patient: Prevention of post-operative nausea and vomiting.
Patient education: Notify a healthcare professional immediately if you notice symptoms of irregular heartbeat, serotonin syndrome or involuntary movement of the eyes, face or limbs occurs.

Oxycodone (Roxicodone)- 5mg tablet oral Q4H

Intended effect for patient: Used for moderate to severe chronic pain.
Patient education: This medication is a drug with known abuse potential. It can cause drowsiness or dizziness avoid activities that require alertness, avoid alcohol and other CNS depressants on this medication, encourage patient to turn and cough along with deep breathe every 2 hours.

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Scheduled:

Acetaminophen- 1,000mg oral Q6H Intended effect for patient: Treatment of mild to moderate pain.

Patient education: Use of 4g or more a day can cause hepatotoxicity, avoid drinking alcohol on this medication it can cause liver failure and discontinue if rash occurs.

Clindamycin (Cleocin)- in DSW 600mg IVPB Q8H
Intended effect for patient: Treatment of osteomyelitis
Patient education: Notify a healthcare professional if you experience diarrhea, abdominal cramping, fever or bloody stools. Notify a healthcare professional if you aren't feeling any better after a few days.

Ketorolac (Toradol)- 15mg IV Q6H
Intended effect for patient: Short-term management of pain
Patient education: May cause drowsiness or dizziness, avoid doing activities that require being alert. Avoid frequent use of alcohol, Aspirin, NSAIDs and Tylenol without consulting a healthcare professional. Consult a healthcare professional if there are signs of rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools or flu-like symptoms.

Sennosides-docusate sodium- 2 tablets oral once daily at bedtime
Intended effect for patient: Treatment of constipation
Patient education: Only used for short-term therapy only. Encourage fluid intake, mobility and  larger diet. Medication may cause urine to turn pink, red, violet, yellow or brown.

Lactated Ringers- 20mL IV continuous Intended effect for patient: Replace fluid and electrolytes
Patient education: Report any nausea, vomiting, abdominal pain and diarrhea to a healthcare professional. If you notice any abnormal signs of redness or swelling around the IV site report immediately.

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Assessment Findings (abnormal or that contribute to clients current state)

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Assessment Findings (abnormal or that contribute to clients current state)

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Pain: 1615 pain rated 0 out of 10 on a 0-10 scale.
Anxiety/Coping/Psychosocial: Patient is anxious to go home from hospital. The patient spent 1 year of drinking alcohol heavily. Has a past history of abusing drugs. One year ago he had a psychiatric evaluation and claims that he has been hearing voices since he was a child. The patient has a history of anxiety and depression. He told the psychologist he saw a year ago that he has frequent panic attacks and the voices he hears tell him to hurt others but he would never do that. The patient has smoked 1 pack of cigarettes a day for the past 4 years. He denied any illicit drug use.
Home/Health Maintenance: The patient has a mother and father in his life. He hasn't ever received dental care due to lack of dental insurance. He lives next to his sister who is someone he confides in. His sister has reported him having psychotic behavior in the past year.
Nutrition/Elimination/GI/GU:
Intake during shift 0701-1900
PO meds 100
Maintenance IV 600ml
Output during shift 0701-1900
Urine 200ml
Blood 75ml
Balance: +425ml
Diet- Mechanical soft started on 02/19/2019
Height-182.9cm
Weight- 84.5 kg
All GI and GU functions are normal, bowel sounds were present.

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Vital Signs:  (Vital signs are taken every 2 hours)
Set #1 Temp- (Axillary) 36.3 Degrees Celsius Pulse- 48 bpm Blood Pressure- 145/80 Respirations- 18 Oxygen Saturation- 98%
Set #2 Temp- (Axillary) 36.8 Degrees Celsius Pulse- 73 bpm Blood Pressure- 134/56 Respirations- 16 per minute Oxygen Saturation- 98%
- Trending analysis was unavailable due to me not being able to access the patient charts. Vital signs weren't concerning except for the 48 bpm for pulse. Bradycardia could have been caused by medication that he was given, smoking and his drug use could have also influenced this. The second set shows that his pulse went back into the normal range.

Labs: All labs taken as routine after surgery

- Hemoglobin 02/19/2019 patient value: 14.0 g/dL normal range: 14-18 g/dL
- Hematocrit 02/19/2019 patient value: 40.7%
C
-Erythrocytes 02/19/2019 patient value: 4.66 normal value for men: 4.35-5.65 cells/L
-Platelet count 02/19/2019 patient value: 366 an abnormally high value. The normal value range for men is 135-317 billion/L. High platelet count can be caused by: Thrombocytosis and iron deficiency anemia. With too many platelets the blood will clot too easily.
Nursing interventions: Assess patient for signs of DVT and pulmonary embolism, ambulating the patient, administering anti-coagulants and applying SCDs.
-Monocyte count 02/19/2019 patient value: 0.89 an abnormally high value. The normal value range is 0.26-0.81. High monocyte count can be caused by: Blood disorders, infection, autoimmune diseases and obesity. Nursing interventions: Assess the patient for new signs of infection, keep a constant monitor on the patient for changes in status. Ask the patient if he has a history of any diseases that aren't in his chart.
- Basic Metabolic Panel 02/19/2019 Patient values: Calcium: 9.8 mg/dL (normal value 8.6-10.0 mg/dL ) Bicarbonate: 29 mmol/L (normal value 22-29 mmol/L) Chloride: 102 (normal value) Creatinine: 0.82 mg/dL (normal value for men 0.74-1.35 mg/dL) Glucose: 107 mg/dL (normal value 70-140 mg/dL) Potassium: 5.5 mmol/L (an abnormally high value, value normal is 3.6-5.2 mmol/L) Sodium: 14.3 (normal value is) BUN: 13 mg/dL (male normal value 8-24 mg/dL)
-Potassium 02/19/2019 value 5.5 mmol/L is a high value. A high potassium value can be caused by: Excessive dietary intake, acute and chronic renal failure, infection or dehydration.
Nursing interventions: Assess ECG and pulse for bradycardia, assess urine output and check patient for nausea and vomiting. Check intake and output status and make sure the patient isn't eating foods with potassium.

Diagnostic tests:
- X-ray imaging of teeth 02/18/2019 Taken to get imaging of the patient's teeth. They found multiple large carries (cavities) of the upper front teeth.
- Actinomyces culture 02/19/2019 Taken to detect if the rare infectious bacteria actinomyces is present, if infected it can cause sores or abscesses in soft tissues. The results didn't come back from the lab at the time I was giving care.
- Bacterial culture 02/19/2019 Taken to help find harmful bacteria present in the patient's body. The results didn't come back from the lab at the time I was giving care.
- Gram stain 02/19/2019 taken to detect the presence of bacteria in a sample from the site of infection. The patient's gram stain had no organisms seen and few white blood cells in the stain.
- Surgical pathology: frozen lab 02/18/2019 mandible tissue was taken during surgery to analyze and diagnose tissue samples. The results didn't come back at the time I was giving care.
- Fungal Culture 02/19/2019 Taken to determine if fungi are present and causing infection. The results didn't come back at the time I was giving care.
- Urine drug screen 03/07/2018 Didn't indicate why the patient's urine was screened for drugs at the time and didn't give values. Results were positive for tetrahydrocannabinol or THC, Tricyclic antidepressants, amphetamines and methamphetamines. Doing these drugs especially amphetamines and methamphetamines cause severe tooth decay and gum disease. Teeth are known to break or fall out.

Specialties/ services collaborating: Infectious diseases did the laboratory tests and cultures to see if the patient has an infectious disease. The infectious disease consult reported that the patient isn't infectious or at risk.

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Subjective: Swelling left side of face. Before surgery pain so severe in his mouth that he couldn't eat. After surgery highest pain rating 5 out of 10 on 0-10 scale.
Objective: Teeth decayed before surgery and abscess with swelling on left mandible before surgery. The removal of teeth causing pain after surgery.
Co-morbidities: N/A

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Age: 23 years old
Gender: Male
Left buccal space abscess
- Hospitalized after maxillofacial surgery a procedure consisting of incision, drainage of left mandibular abscess via intra oral and extra oral approaches. Debridement, irrigation of wound on left mandible, debridement right mandible. Removal of 6 teeth during operation. Concern for osteomyelitis.