POC & CONCEPT MAPS WEEK 12 1

Clinical Plan of Care and Concepts Maps

Valerie M. Ganley WNCSN

Western Nevada College

Professor Debi Ingraffia-Strong PhD©, MSN, RN

Instructor Lisa Dunkelberg, MSN, RN

Instructor Raylene Stiehl MSN, RN

Instructor Heather Reardon MSN, RN

Clinical Week 12

April 16, 2019

 POC & CONCEPT MAPS WEEK 12 2

Pain/Mobility Elimnation Genitourinary

Full active movements x4. Up self, Neurological/Thermoregulation
Self void, urinal. Yellow, clear, 300 mLs. UA:
SBA with IV Pole PRN. No swelling Alert and oriented x4. PERRLA 3mm. normal except 4+ glucose.
or tenderness in joints. Fall risk due to Normal speech. Temp: 98.2. Gag reflex
Oxycodone (PRN q4hrs) & weakness present (cough). Gaslow score 15.
r/t pain. Pain 7/10 prior to pain med Purposeful motor response x4.
administration. Pain upon palpation of
abd. Enlarging psuedocyst. Pain 3/10,
30 minutes after, during reassessment.

57-Year-Old- Male. Full code. No known allergies.

Not married. Lives at home with mother.
Metabolism
Active bowel sounds x 4. Soft, tender, mild
distention. LBM: 4/16/19, UTA. Given
Admitting Diagnosis: Docusate-Senna, Pepcid for gastric
Oxygenation “Diabetic Issues” secretions, Fenofibrate for hyperlipidemia.
Glucose 61 upon admission. Hypoglycemia. A1c: 5.9: Insulin subq. Agressive fluids:
Respirations 18/ O2 Sat: 95 RA. Clear, LR 1000mL. Lipase elevated: 203.
symmetrical breath sounds bilaterally. Triglycerides: 89. Smoker, denies alcohol
Capillary refill < 3 seconds. Denies chest use. Na+ low: 132. Cl: 97. Alb 2.5: wasn't
pain and SOB. eating & experienced N/V/D. Full liquid
Past Medical History: diet upgraded to Reg diet Dys III.
Type 2 DM, Hyperlipidemia, Hypertension, CAD,
Anxiety, Current Smoker. Previous visit DKA.
Pancreatic pseudocyst. Heavy drinker and
recreational drug user in the past. Stopped in the
80s.
Perfusion
Regular rate and rhythm. HR 88.
Capillary refil < 3 seconds. Radial and
pedal pulse 2+. BP: 99/72. Lisinopril Psychsocial
held 0900 med pass. BP 107/75 1200
VS. INR: 1.2, will continue to monitor. Tissue Integrity Calm, cooperative. Mood appropiate
Enoxaparin for anticoagulation. Alb for situation except knowledge deficit
Warm, dry, intact, pink with no concerning disease process. Actively
low: 2.5. WBC elevated:14.9. Hgb: abnormal color. Turgor returns < 3
15.8. Plt: 523 elevated, Thrombocytosis participates. Denial of disease
seconds. Braden score: 23. 20 g PIV process. Family in life. Tobacco
due to elevated state. Monitor fluids. in Lt UA. dependent. Nicotine patch refused.
 POC & CONCEPT MAPS WEEK 12 3

Nursing Interventions: Nursing Goals: Patient Education &

• Explan the causes of chronic • Patient will relate satisfactory Health Promotion:
pancreatitis. relief after pain-relief • Teach patient about all aspects of
interventions. the therapeutic regimen, providing
• Evaluate understanding of dietary
needs and restrictions. • Patient will relate effective as much knowledge as the patient
interventions to relieve pain. is willing to accept.
• Maintain pain management PRN.
• Patient will rate pain level lower • Educate patient on self-
• Reassess pain throughout shift. after measures.
• Monitor for s/s of hypovolemia management of the medical
• The patient will acknowledge regimen.
and shock: Increasing PR, normal alcohol problem (if he is denying).
or slightly decreased BP, • Teach patient importance of
increasing RR, urine output <5 • Patient will demonstrate smoking cessation.
ml/kg/hr, restlessness, agitation, understanding of disease process • Teach patient importance of
change in mentation, dimished and understand that low blood glucose monitoring, and the need
peripheral pulses, cool, pale, or sugar can kill him. to monitor BS at home.
cyanotic skin. • Patient will describe daily food and • Teach patient to report early
• Monitor for respiratory fluid intake that meets therapeutic worsening symptoms of: clay
complications: Hypoxemia, goals. colored stools, increase in pain in
Atelectasis, Pleural effusion. • Patient will describe scheduling of upper left side, mid abd, and or
• Monitor for SIRS. medications that meet therapeutic radiating to back, persistent
goals. gastritis, N/V, weight loss, and
• Monitor for metabolic
complications: Hypokalemia, • Patient will verbalize ability to elevated temperature.
hiccups. manage therapeutic regimens. • Teach deeping breathing exercises
• Monitor hematologic • Patient will collaborate with health in times of pain.
complications. professionals to decide on a • Teach patient the use of incentive
therapeutic regimen that is spirometry.
• Monitor coagulation profiles, congruent with health goals and
H&H, hypoalbuminemia. lifestyle.
• Evaluate whether or not pt abuses • Patient will demonstrate interest in
alcohol. smoking cessation.
• Monitor thrombocytosis. • Patient will use IS 10x/hr.
• Idenify patient's current
knowledge and adjust teaching
accordingly.
 POC & CONCEPT MAPS WEEK 12 4

Nursing Diagnosis:
Acute pain related to irritation and edema
of inflamed pancreas as evidence of patient
rating pain as 7/10 and stating "it hurts
above my stomach."

Evaluation:
• Patient rated pain relief of 3/10 after pain Subjective:
med administration at 1000. Patient rated pain 7/10 and stated, "it hurts
• Patient demonstrated little to no interest above my stomach."
about disease process. Objective:
• Patient joked about his disease process. Pointed to stomach, mid-abd, upper left
side. Winced during palpation.

Teaching: Goals/Outcomes
• Teach patient importance of BS monitoring. Short Term:
• Explain causes of chronic pancreatitis.
• Educate patient on self-management of the Patient will relate satisfactory relief after
medical regimen. pain med administration by lunch.
• Advise patient to call when he is in pain. Long Term:
• Teach patient importance of smoking Patient will state an acceptable rate of painor
cessation. no pain by discharge.
Interventions:
• Maintain pain management PRN.
• Reassess pain throughout shift.
• Monitor IV fluids.
• Monitor urine output.
 POC & CONCEPT MAPS WEEK 12 5

Nursing Diagnosis:
Ineffective Health Maintenance related to
deficient knowledge concerning diet,
disease process (DM type 2), smoking, and
stating "you can't die from low blood
sugar."

Evaluation: Subjective:
• Patient joked about the need to check his Patient stated, "you can't die from low
BS. blood sugar."
• Patient demonstrated little to no interest Objective:
about disease process and smoking 4 Units sliding scale insulin given. A1c:
cessation. 5.9. Admission glucose of 61.

Teaching: Goals/Outcomes
• Teach patient about all aspects of the Short Term:
therapeutic regimen, providing as much Patient will demonstrate importance of
knowledge as the patient is willing to monitoring BS by end of shift.
accept.
Long Term:
• Teach patient about disease process and
explan that low blood sugar can kill him. Patient will verbalize ability to manage
Interventions: therapeutic regimens by discharge.
• Idenify patient's current knowledge and
adjust teaching accordingly.
• Explan the causes of chronic
pancreatitis.
• Evaluate whether or not patient abuses
alcohol.
• Evaluate understanding of dietary needs
and restrictions.
 POC & CONCEPT MAPS WEEK 12 6

Labs & Diagnostics (from prior care plan example) Must show trending…i.e. increasing, decreasing, stabilized, baseline)
[include all relevant normal & abnormal tests and analyze the results as related to this patient]
Test Date Result Trending Analysis
4/15/19 14.9 Normal Range WBC count indicates the possible presence and severity of
WBC-Leukocytes (4.5-11 x 103 cell/ infection or inflammatory response. Performed with CBC to
uL) evaluate a specific problem.
WBC 4/17/19 13.6 ^^^ Trending down. Patient has chronic pancreatitis.
4/15/19 5.0 Normal Range RBC may be part of routine CBC or may be repeated as a single
(Male: 4.6-6.0 x test when the patient’s health condition includes an abnormal
RBC- Red Blood Cells 106/uL) altered RBC. Also used to evaluate anemia and polycythemia.
(Female: 4.0-5.4 x
106/uL)
RBC 4/17/19 4.7 ^^^
4/15/19 15.8 Normal Range Used to measure the severity of anemia or polycythemia, and it
(Male: 14.0-18.0 monitors the response to treatment of anemia. An elevated Hgb
g/dL) value may be a result of either excess production of erythrocytes
HGB-Hemoglobin (Female: 12.0-15.0 by the bone marrow or dehydration which the patient was
g/dL) experiencing. In dehydration, the RBC counts and Hgb are
relatively high because of the normal number and quality of cells
that are concentrated in a smaller amount of fluid.
4/17/19 13.6 ^^^ Patient experienced episodes of N/V/D which results in
HGB
dehydration.
4/15/19 47.2 Normal Range Is useful in evaluation of blood loss, anemia, hemolytic anemia,
(36-50) polycythemia, and dehydration. Hct rises if the number or size of
the erythrocytes increases or when the plasma fluid volume is
HCT-Hematocrit
reduced. When fluid volume is decreased, the RBC become
concentrated in the smaller fluid volume. Blood is thicker or has
increased viscosity.
4/17/19 40.9 ^^^ Trending down. Patient experienced N/V/D and was NPO which
HCT
resulted in dehydration.
PLT - Platelets 4/15/19 523 Normal Range Used to assess the ability of the bone marrow to produce platelets
 POC & CONCEPT MAPS WEEK 12 7

(150-450 x 109/L) and to identify the destruction or loss of platelets in the
circulation. Also used to evaluate the untoward effects of
chemotherapy or radiation treatment. Platelets function to initiate
the process of coagulation.
4/17/19 439 ^^^ Trending down. Thrombocytosis with elevated platelets due to
PLT
inflammatory state. Patient receiving Lovenox for coagulopathy.
4/15/19 132 Normal Range Sodium level is used to monitor electrolyte balance, water
(135-145 mEq/L) balance, and acid-base balance. It is used for evaluation of
Na+ - Sodium
disorders of the CNS, musculoskeletal disorders, or disease of the
kidneys or adrenal glands.
4/17/19 134 ^^^ Hyponatremia. Mildly low. Patient was recently admitting for
Na+
DKA, experienced N/V.
4/15/19 4.1 Normal Range Potassium levels are used to evaluate electrolyte balance, acid-
(3.5-5 mEq/L) base balance, hypertension, renal disease, or renal failure, and
K+ - Potassium endocrine disease. It is used to monitor patients receiving
treatment for ketoacidosis, hyperalimentation, dialysis, diuretic
therapy, or IV fluid and electrolyte replacement.
K+ 4/17/19 4.0 ^^^ Patient’s K+ fluctuated because of dehydration.
4/15/19 98 Normal Range Chloride is used in evaluation of electrolyte levels, water
Cl -Chloride
(95-105 mEq/L) balance, and acid-base balance, and anion gap.
Cl- 4/17/19 101 ^^^ Patient was recently admitting for DKA, experienced N/V.
4/15/19 8.4 Normal Range Are used to assist in the diagnosis of acid-base imbalance,
Ca - Calcium (8.8-10.2 mg/ dL) coagulation disorders, pathologic bone disorders, endocrine
disorders, cardiac arrhythmia, and muscle disorders.
4/17/19 8.3 ^^^ Decreased calcium levels indicates hypocalcemia and vitamin D
deficiency, and malnutrition to name a few. Patient was
Ca+
previously not eating and had a poor diet. He had been NPO and
would not eat because pain would occur an hour after .
4/15/19 26 Normal Range Is used to help evaluate acid-base balance and the bicarbonate
CO2-Carbon Dioxide (23-29 mEq/L) buffer system. The concentration of CO2 is controlled by the lungs
and the concentration of bicarbonate is controlled by the kidneys.
CO2 4/17/19 23 ^^^ Decreased CO2 values can be caused diarrhea and dehydration
 POC & CONCEPT MAPS WEEK 12 8

which the patient experienced.
GLUC-Glucose 4/15/19 61 Normal Range Glucose is evaluated to diagnose and manage patients with
(79-160 mg/dL) diabetes mellitus.
GLUC 4/17/19 87 ^^^ Patient has knowledge deficit regarding disease process. Poor
DM management.
BUN- Blood Urea Nitrogen 4/15/19 27 Normal Range BUN is used to evaluate renal function and used to monitor
(7-20mg/dL) patients in renal failure or patients receiving dialysis therapy.
Decreased values may indicate overhydration, starvation, IV
therapy, low-protein diet, acromegaly, severe liver damage.
BUN 4/17/19 10 ^^^ Trending down, patient was not eating.
Cr-Creatinine 4/15/19 0.57 Normal Range Serum creatinine is to evaluate renal function and to estimate the
(0.6-1.2 mg/ dL) effectiveness of glomerular function.
Cr 4/17/19 0.54 ^^^ Indicator of possible muscle wasting from not eating.
Mg-Magnesium 4/15/19 Not Tested Normal Range Is used to evaluate renal function and to stage chronic renal
(130 mL/min) disease.
4/17/19 Not Tested
PT-Prothrombin time 4/15/19 15.2 Normal Range Helps to evaluate electrolyte disorders, hypocalcemia,
(10- 14 Seconds) hypokalemia, and acid-base imbalance.
4/17/19 Not Tested ^^^ Elevated values indicate hepatobiliary or pancreatic obstruction.
INR-Int. Normalized Ratio 4/15/19 1.2 Normal Range Helps diagnose kidney disorders and acid-base imbalance. Also
(2.8-4.5 mg/dL) used to detect disorders of calcium, bone, and endocrine origin.
4/17/19 Not Tested ^^^ Patient has poor management of DM.
AST-Aspartate 4/15/19 20 Normal Range Is used to detect hepatocellular injury or necrosis. Most specific
Aminotransferase Female 60-90: to detect acute hepatitis from a viral, toxic, or drug-induced
(10-28 IU/L) caused. It is used to help determine the source of jaundice.
AST 4/17/19 Not Tested ^^^
ALT-Alanine 4/15/19 55 Normal Range Is used as a nonspecific indicator of liver disease, biliary tract
Aminotransferase (Females 20-50: obstruction, bone disease, or hyperparathyroidism. It is part of a
42-98 U/L) battery of tests that evaluate liver function. Also serves as a tumor
 POC & CONCEPT MAPS WEEK 12 9

(Females 60 & Up: marker by indicating rapid cell growth or accelerated function
53-141 U/L) caused by malignancy of the liver or bone.
ALT 4/17/19 Not Tested ^^^ Trending down. According to CTH the first value was elevated
which may indicate liver disease. The patient’s labs are
appearing to indicate issues with liver, renal, or endocrine
systems.
Protein 4/15/19 5.1 Normal Range Provides general information about patient’s nutritional status
(6.4-8.3 g/dL) and the severity of diseases of the liver, bone marrow, and
kidneys. Also used to investigate cause of edema.
Pr 4/17/19 5.5 ^^^ Patient was not eating prior to admission. Decreased levels
indicate malnutrition.
Albumin 4/15/19 2.5 Normal Range Is used in detection of hepatobiliary disease and monoclonal
(3.5-5.0) gammopathy, and in the evaluation of nutritional status.
Alb 4/17/19 2.0 ^^^ Patient was not eating. Indicates moderate protein calorie
malnutrition.
Lipase 4/15/19 203 Normal Range Lipase is a pancreatic enzyme needed to help digest fatty acids. In
(< 200 units/L) pancreatic inflammation, this enzyme cannot flow into the
intestine because of inflammation or blockage in the pancreas,
pancreatic duct, common bile duct, or intestine. Once there is
obstruction, the lipase is secreted into the blood and the serum
level rises.
Li 4/17/19 186 ^^^ Elevated lipase indicated chronic pancreatitis.
Lipid Profile (Triglycerides) 4/15/19 89 Normal Range Lipid levels are used to identify individuals at risk for CAD and
(< 150 mg/dL) as an evaluation tool to determine the effectiveness of “heart
healthy” changes in lifestyle.
Lipid Not tested ^^^ Patient has a history of CAD.
EKG 4/15/19 Showed sinus rhythm at 88 bpm with normal R-wave progression,
normal T-waves, normal intervals.
Radiology (CT Scan) 4/15/19 CT of abdomen and pelvis showed pancreatic calcification
consistent with chronic pancreatitis. There is an enlarging cystic
collection at the anterior aspect of the pancreatic body,
measuring 11.3 x 6.6 x 7.5 (pancreatic pseudocyst).
 POC & CONCEPT MAPS WEEK 12 10

Medications – Current Medications and all PRN’s

PEPCID Davis Pages: 637-639
Trade Name Pepcid
Generic Name Famotidine
Drug Class Histamine H2 Receptor Antagonists/ Antiulcer
Route(s) PO: 40 mg/daily at bedtime or 20 mg twice daily, for up to 8 weeks initially (Maintenance dose: 20 mg/daily). IV: 20 mg q
12 hours, diluted and given over 2 minutes.
Drug Indications Treatment of active duodenal ulcers and GERD. Management of gastric hypersecretory states (Zollinger-Ellison Syndrome).
IV: Prevention and treatment of upper GI bleed.
Mechanism of Action Inhibit the action of histamine at the H2 receptor site located primarily in gastric parietal cells, resulting in inhibition of
gastric acid secretion.
Onset of Action Within 60 Minutes
Duration of Action 8-15 Hours
Contraindications Hypersensitivity; Some products contain alcohol and should be avoided in patients with known intolerance; Some products
contain aspartame and should be avoided in patients with phenylketonuria. Use caution with patient with renal impairment.
Drug Interactions Famotidine, nizatidine, and ranitidine have a much smaller and less significant effect on the metabolism of other drugs
Adverse Effects CNS: Confusion, dizziness, drowsiness, hallucinations, headache. CV: Arrhythmias. GI: Constipation, diarrhea, nausea,
drug-induced hepatitis. GU: Decreased sperm count, impotence. Endo: Gynecomastia. HEMAT: Agranulocytosis, aplastic
anemia. MISC: Hypersensitivity reactions.
Nursing Considerations Before giving this drug, I will check the CBC and differential counts daily. Advise patient that other medications may be
(Before giving this drug, I less effective because of increased stomach pH. I will teach the patient to take the medication as directed for the full course
will…) of therapy. Notify HCP if difficulty swallowing occurs if abdominal pain persists. Smoking interferes with the action of
histamine receptor antagonists. Avoid alcohol, products containing aspirin or NSAIDs, excessive amounts of caffeine, and
foods that may cause an increase in GI irritation. Report immediately signs of bone marrow suppression, such as bleeding,
purpura, and sore throat. Report confusion or hallucinations immediately.
 POC & CONCEPT MAPS WEEK 12 11

FENOFIBRATE Davis Pages: 543-544
Trade Name Antara, Fenoglide, Lipofen, Lofibra, Ticor,
Generic Name Fenofibrate
Drug Class Lipid-lowering agent/Fibric Acid Derivative
Route(s) PO: 145 mg/day
Drug Indications Management of type IIb hyperlipidemia (decreased HDL, increased LDL, increased triglycerides) in patients who do not yet
have clinical CAD and have failed therapy diet, exercise, weight loss, or other agents (niacin, bile acid sequestrants).
Mechanism of Action Inhibits peripheral lipolysis. Decreased triglyceride carrier protein. Increased HDL.
Onset of Action Unknown
Duration of Action Unknown
Contraindications Hypersensitivity; Hepatic impairment (including primary biliary cirrhosis), severe renal impairment, concurrent use of
HMG-CoA reductase. Use cautiously with concurrent use of warfarin.
Drug Interactions Increased anticoagulant effects of warfarin. HMG-CoA reductase inhibitors increases risk of rhabdomyolysis (concurrent
use should be avoided). Absorption is decreased by bile acid sequestrants (fenofibrate should be given 1 hour before or 4 – 6
hours after). Increased risk of nephrotoxicity with cyclosporine. Concurrent use with colchicine may increase risk of
rhabdomyolysis.
Adverse Effects CNS: Dizziness, headache. EENT: Blurred vision. GI: Abdominal pain, D/N/V, epigastric pain, flatulence, gallstones,
heartburn. DERM: Alopecia, rash, urticaria. HEMAT: Anemia, leukopenia. MS: Myositis.
Nursing Considerations Before giving this drug, I will assess lipid panel, LFT, CBC, and electrolytes at baseline, and periodically while on
(Before giving this drug, I medication. Administration of these drugs with HMG-CoA reductase inhibitors increases the risk for rhabdomyolysis that
will…) can result in renal failure. This medication should be used in conjunction with dietary restrictions, exercise, and cessation of
smoking.
 POC & CONCEPT MAPS WEEK 12 12

HUMALOG Davis Pages: 691. Mosby’s Pages: 671-674
Trade Name Humalog (Rapid-Acting Insulin)
Generic Name Insulin Lispro, rDNA Origin
Drug Class Antidiabetic Agent, hormone/ Pancreatic Agents
Route(s) SC: 0.2-0.6 unit/kg/daily
Drug Indications Treatment of diabetes mellitus. Very rapid acting.
Mechanism of Action Lowers blood glucose by stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production. Other
actions are inhibition of lipolysis and proteolysis.
Onset of Action 5-15 minutes. Peak 30-60 minutes.
Duration of Action 3-5 hours
Contraindications Hypersensitivity to protamine, creosol.
Drug Interactions Increase: Hypoglycemia-salicylate, alcohol, B-blockers, anabolic
steroids, phenylbutazone, sulfinpyrazone, guanethidine, oral hypoglycemics, MAOIs, tetracycline. Decrease: Hypoglycemia-
thiazides, thyroid hormones, oral contraceptives, corticosteroids, estrogens, Dobutamine, Epinephrine. Increase: VMA,
Decrease: K+, Ca. Interference: LFTS, thyroid function studies.
Adverse Effects DERM: Urticaria. ENDO: Hypoglycemia, rebound hyperglycemia (Somogyi effect). RESP: Bronchospasm with inhaled
insulin. LOCAL: Lipodystrophy, itching, redness, swelling. MISC: Allergic reactions, including anaphylaxis.
Nursing Implications Because of the higher error rate, two nurses should check the insulin type, dosage, and expiration date. Very rapid-
acting agents are called “dose and eat” for a reason. Memorize the peak time of these medications! Look for
hypoglycemia (Normal 70-120 mg/dL). Hypoglycemia resembles an anxiety attack, with the person having cold, clammy
skin. Teach: Use U-100 syringes with solutions 100 units/mL. If using a prefilled pen, prime with 2 units prior to dialing
dosage. Sick days require more monitoring. Carry a source of glucose. Wear a Medic-Alert bracelet. Recognize s/s of
hyperglycemia and hypoglycemia and be aware of self-treatment measures if these occur.
 POC & CONCEPT MAPS WEEK 12 13

OXYCODONE HIGH ALERT!!! Mosby’s Pages: 943-945. Davis Pages: 940-942
Trade Name Oxy IR
Generic Name Oxycodone/Acetaminophen
Drug Class Opioid analgesic/Opioid Agonists and nonopioid combinations.
Route (s) 10 mg PO q4 hours PRN Severe (7-10)
Drug Indications Management of moderate to severe pain.
Mechanism of Action Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli, while producing generalized
CNS depression.
Onset of Action 10-15 minutes.
Duration of Action 3-6 Hours.
Contraindications Hypersensitivity. Some products contain alcohol or bisulfites and should be avoided in patients with known intolerance or
hypersensitivity, significant respiratory depression, paralytic ileus; Acute or severe bronchial asthma. Acute, mild,
intermittent, or postoperative pain (extended-release). Use Cautiously in: Head trauma, increase intracranial pressure, severe
renal or hepatic disease, hypothyroidism, adrenal insufficiency, alcoholism, seizure disorders; Undiagnosed abdominal pain,
prostatic hyperplasia, difficulty swallowing or GI disorders that may predispose patient to obstruction (increased risk for GI
obstruction).
Drug Interactions Use with caution in patients receiving MAO inhibitors (may result in unpredictable reactions increase initial dose of
oxycodone to 25% of usual dose). Additive CNS depression with alcohol, antihistamines, and sedative/hypnotics.
Administration of partial-antagonist opioid analgesics may precipitate withdrawal in physically dependent patients.
Nalbuphine, buprenorphine, or pentazocine may decrease analgesia. Potent CYP3A4 inhibitors including erythromycin,
ketoconazole, itraconazole, voriconazole, or ritonavir may increase levels. Potent CYP3A4 inducers including rifampin,
carbamazepine, and phenytoin may decrease levels.
Adverse Effects CNS: Confusion, sedation, dysphoria, euphoria, floating feeling, hallucinations, headache, unusual dreams. EENT: Blurred
vision, diplopia, miosis. RESP: Respiratory depression. CV: Constipation, N/V. GU: Urinary retention. DERM: Sweating.
MISC: Physical dependence, psychological dependence, tolerance.
Nursing Considerations Before giving this drug, I will assess type, location, and intensity of pain prior to and 1 hour (peak) after administration.
(Before giving this drug, I When titrating opioid doses, increases of 25 – 50% should be administered until there is either a 50% reduction in the
will…) patient’s pain rating on a numerical or visual analog scale or the patient reports satisfactory pain relief. A repeat dose can be
safely administered at the time of the peak if previous dose is ineffective and side effects are minimal. Naloxone (Narcan)
is the antidote. Treatment of overdose: Narcan 0.2-0.8 mg IV, O2, IV fluids, vasopressors, caution in patients physically
dependent on opioids.
 POC & CONCEPT MAPS WEEK 12 14

DOCUSATE Davis Pages: 443-444. Mosby’s Pages: 405-406
Trade Name Colace, Senna
Generic Name Docusate Calcium (OTC)
Drug Class Laxative, Stool Softener
Route(s) PO: 50-300 mg/day (sodium) or 240 mg (calcium)
Drug Indications Prevention of dry, hard stools
Mechanism of Action Promotes incorporation of water into stool, resulting in softer fecal mass. May also promote electrolyte and water secretion
into the colon.
Onset of Action 12-72 Hours
Duration of Action Unknown
Contraindications Hypersensitivity, obstruction, fecal impaction, nausea, vomiting.
Drug Interactions Toxicity: Mineral Oil. Increase laxative action- flax, Senna.
Adverse Effects EENT: Bitter taste, throat irritation. GI: Nausea, anorexia, cramps, diarrhea. DERM: Rash
Nursing Considerations This medication does not stimulate intestinal peristalsis; stimulant laxative may be required for constipation. PO:
(Before giving this drug, I Administer with a full glass of water or juice. May be administered on an empty stomach for more rapid results. Oral
will…) solution may be diluted in milk, infant formula, or fruit juice to decrease bitter taste. Do not administer within 2 hr of other
laxatives, especially mineral oil. May cause increased absorption.
 POC & CONCEPT MAPS WEEK 12 15

LISINOPRIL Davis Pages: 161-167
Trade Name Lisinopril
Generic Name Prinivil, Zestril
Drug Class Antihypertensive agent/ACE Inhibitor
Route(s) PO: 10-40 mg/day
Drug Indications Used alone or with other agents in the management of HTN. Reduction of death or development of CHF after MI. Slowed
progression of left ventricular dysfunction.
Mechanism of Action ACE Inhibitors block the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. They also inhibit the renin-
angiotensin-aldosterone (Body’s salt) in the bloodstream.
Onset of Action 1 Hour
Duration of Action 24 Hours
Contraindications Hypersensitivity; History of angioedema with previous use of ACE inhibitors
Drug Interactions Excessive hypotension may occur with concurrent use of diuretics.
Additive hypotension with other antihypertensive agents. Risk of hyperkalemia with concurrent use of potassium
supplements, potassium-sparing diuretics, or potassium-containing salt substitutes.
Adverse Effects CNS: Dizziness, fatigue, headache, weakness. RESP: Cough. CV: hypotension, chest pain, tachycardia. GI: Taste
disturbances, anorexia, abdominal pain, N/V/D, hepatotoxicity (rare). GU: erectile dysfunction, impaired renal function.
DERM: Rashes. F and E: Hyperkalemia. MISC: ANGIOEDEMA, fever. HEMAT: BMS.
Nursing Considerations Before giving this drug, I will always take the BP prior to administration. Monitor BP and pulse frequently during
(Before giving this drug, I initial dose adjustment and periodically during therapy. Assess patient for signs of angioedema (dyspnea, facial
will…) swelling). Monitor RFT, LFT, CBC, serum glucose, and K+ increase. May cause increase in BUN and serum creatinine.
Asses for signs of CHF. Monitor I&O and daily weight.
 POC & CONCEPT MAPS WEEK 12 16

LACTATED RINGERS Lewis, Dirksen, Heitkemper, Butcher, Harding. Pg: 292

Trade Name Lactated Ringers
Generic Name Sodium Chloride, Sodium Lactate, Potassium Chloride & Calcium Chloride
Drug Class Fluid and Electrolyte Balancer
Route(s) Intravenous Solution, IV.
Drug Indications As a source of water and electrolytes or as an alkalinizing agent.
Mechanism of Action USP produces a metabolic alkalinizing effect. Lactate ions are metabolized ultimately to carbon dioxide and water, which
requires the consumption of hydrogen cations. Restores fluid and electrolyte balances and produces diuresis.
Onset of Action Rapid
Duration of Action Duration of infusion
Contraindications Patients with liver dysfunction, hyperkalemia, and severe hypovolemia. History of hypersensitivity to sodium lactate. Other
calcium-containing infusion solutions must not be administered simultaneously with intravenous calcium-containing
solutions, including Lactated Ringer’s. Use cation in those with renal impairment.
Drug Interactions Do not use with ceftriaxone (Rocephin) due to the significant risk of ceftriaxone and calcium precipitation. May increase the
risk of sodium and fluid retention in use with corticosteroids. Use caution in patients treated with agents or products that can
cause hyperkalemia or increase risk of hyperkalemia, such as potassium sparing diuretics, with ACE inhibitors, angiotensin
II receptor antagonists, or the immunosuppressants tacrolimus and cyclosporine. Renal clearance of acidic drugs may
increase and alkaline may decrease. May increase risk of hypercalcemia.
Adverse Effects Chest pain, abnormal heart rate, decreased blood pressure, troubled breathing, cough, sneezing, rash, itching, and headache.
Infection at the site of injection, venous thrombosis or phlebitis at the site of injection, extravasation, and increased fluid
volume (hypervolemia) may also occur.
Nursing Considerations Before giving this drug, I will assess for allergies and stop infusion immediately if any signs or symptoms of a suspected
(Before giving this drug, I hypersensitivity reaction develop. I will evaluate the patient and initiate appropriate therapeutic countermeasures. Should not
will…) be administered simultaneously with blood through the same administration set because of the likelihood of coagulation.
Monitor vital signs and for fluid retention.
 POC & CONCEPT MAPS WEEK 12 17

LOVENOX HIGH ALERT! Davis Pages: 634-637 Mosby’s Pages:456-458
Trade Name Lovenox
Generic Name Enoxaparin
Drug Class Anticoagulant, Antithrombotic. Low-Molecular-Weight Heparin
Route(s) SC: 30-40 mg daily
Prophylaxis in knee replacement: 30mg q12 hours given12-24hrs postop for 7-10 days.
Prophylaxis DVT/PE: 20mg daily
Drug Indications Prevention of DVT, PE, in hip and knee replacement, abdominal surgery at risk for thrombosis, unstable angina, acute MI,
coronary artery thrombosis. Used in very low doses (10 – 100 units) to maintain patency of IV catheters (heparin flush).
Mechanism of Action Binds to antithrombin III inactivating factors Xa/IIa, thereby resulting in a higher ratio of anti-factor Xa to IIa.
Onset of Action 3-5 Hours
Duration of Action 12 Hours
Contraindications Hypersensitivity to this med, heparin, pork, active major bleeding, hemophilia, leukemia with bleeding,
thrombocytopenic purpura, heparin-induced thrombocytopenia.
Drug Interactions Increase: Enoxaparin action, anticoagulants, salicylates, NSAIDS, antiplatelets, thrombolytics, RU-486, SSRIs, Monitor
INR/PT. Drug/Lab: Increase in AST, ALT. Decrease in platelet count. Increase bleeding risk, feverfew, garlic, ginger,
ginkgo, green tea, horse chestnut.
Adverse Effects CNS: Fever, confusion. GI: Nausea. HEMA: Hemorrhage from any site, hypochromic anemia, thrombocytopenia,
bleeding. DERM: Ecchymosis, injection site hematoma. META: Hyperkalemia in renal failure. MS: Osteoporosis. SYST:
Edema, peripheral edema, angioedema, anaphylaxis.
Nursing Considerations Monitor for hypersensitivity, CBC with platelets, D-dimers studies, and LFT. Assess for any signs of bleeding and
(Before giving this drug, I hemorrhage. Teach: Report any symptoms of unusual bleeding or bruising immediately. Do not concurrently take
will…) antiplatelet agents. Use soft-bristle toothbrush and an electric razor. Wear Medic Alert bracelet at all times. Follow
instructions on proper method of injecting med. Lovenox is given in the “love handles.” Antidote is Protamine sulfate.
POC & CONCEPT MAPS WEEK 12 18

Clinical Manifestations Pathophysiology: Clinical

Patient S/S: Manifestations Labs &
The outlet of the pancreas may become blocked due Diagnostics:
• Severe midline to inflammation, mechanically (gallstones), or by the
abdominal pain that digestive enzymes being prematurely activated while • Elevated ALT and
radiates to the flank, they are still in the pancreas. Protease causes dilation AST, amylase, lipase,
spine, and back. and permeablility of the capillaries, allowing fluid to ALP, bilirubin, LDH,
• Pain is lessened by move from the pancreas to the retroperitoneal space. potassium, and
drawing the knees up If fluid loss is severe, shock may occur. Protease glucose.
and worsened with initiates a chain reaction that results in conversion of • Low blood pressure
extension of the legs or prothrombin to thrombin, causing DIC. and increase pulse
ingestion of food. indicates shock.
• Complications: Shock, • CT scan and US to
respiratory distress show infiltrates in the
• Renal failure retroperitoneal and
• Signs of hemorrhage: pleural spaces.
Turner's sign (a purple
discoloration in the
flanks) & Cullen's sign
(a purple discoloration Pancreatitis
around the umbilicus). Usual Treatments:
Meds, Vaccinations,
Treatments
IV infusion of fluids,
volume expanders, and
Nursing Considerations: PRBCs.
Anticipated Nursing
Diagnoses: • Monitor pain level and medicate as Oxygen
needed. IV analgesics
• Acute Pain • Assess vital signs for increased pulse
• Risk for Deficient Fluid (meperidine rather than
and decreased BP. morphine to lessen
Volume/Bleeding • Monitor amylase and lipase levels and spasm of the sphincter
• Risk for Unstable Blood F & E levels. of Oddi)
Glucose Level • Assess for Turner's or Cullen's sign.
• Imbalanced Nutrition: Antiemetics
• Teach patient chronic alcohol
Less than body ingestion is a causative factor in NPO to avoid
requirements pancreatitis and Cholelithiasis may worsening
• Risk for Infection cause mechanical obstruction. autodigestion.
 POC & CONCEPT MAPS WEEK 12 19

Pathophysiology:
Clinical Manifestations
Type 2 diabetes increases in incidence
Patient S/S: with obesity, poor diet, and sedentary Clinical Manifestations
• Sedentary lifestyle lifestyle as the cells of the body Labs & Diagnostics:
• Elevated fasting blood become resistant to insulin. Genetic • Glucose, fasting, whole
glucose levels link (10 new gene variants that affect blood
• Elevated postprandial blood glucose and insulin levels have • Glycosylated
glucose levels been identified). Type 2 diabetes is hemoglobin assay
affecting more children related to poor • Anion Gap
• Weight loss diet and obesity.
• Polyuria, Polydipsia, • Electrolytes, serum
Polyphagia • Ketone bodies, blood
• Elevated • Ketones, urine
glycohemoglobin • Osmolarity, plasma
levels
Diabetes
Mellitus
Type 2
Anticipated Nursing Usual Treatments:
Diagnoses:
Meds, Vaccinations,
• Deficient Treatments
Knowledge
regarding disease • Oral hypoglycemic
process agents and drugs to
Nursing Considerations: lower insulin resistance;
• Risk for unstable insulin may be required
blood Glucose Level • Monitor HgbA1c and serum glucose
levels; monitor for complications. if these meds are
• Risk for Infection ineffective or the
• Monitor glucose level before meals and
• Risk for Disturbed at bedtime. Learn the symptoms of low patient is ill (increases
Sensory Perception blood glucose and report if it occurs. glucose levels).
• Teach patient to: • Nutritional consult and
• Follow dietary, exercise, and med exercise regimen.
regimen. • Assessment for cardiac
• Check feet for sores. status with stress
testing, lipid profile,
• Report sensation or vision changes. cardiac rhythm strip.
• Renal tests
 POC & CONCEPT MAPS WEEK 12 20

Pathophysiology:
CAD results in interruption of blood flow that can cause Clinical Manifestations
ischemia or infarction as a result of atherosclerosis. The
inflammation attracts low-density lioproteins (LDL) and Labs & Diagnostics:
binds them to the site. The triglyceride core of the LDLs is • Cardiac Catheterization
spilled into the underlayer of the intima. Macrophages • Cardiac markers
envelop these fats and are now termed "foam cells." This is
a "fatty streak" seen in early stages of stherosclerosis. As • Electrocardiogram
the area englarges, more LDL, macrophages, platelets, and • Stress testing, cardiac
smooth muscle fibers are drawn to the site and accumulate • Cholesterol, total, serum or
under the intima, narrowing the vessel. This causes reduced plasma
blood flow and higher blood pressure in the small coronary • C-reactive protein
vessels. • Homocysteine, plasma
• Lipids, serum
Clinical Manifestations • Ultrafast CT scan to dtect
Patient S/S: calcium deposits in the
• Shortness of breath ateries.
with activity in a Coronary
patient with risk factors Artery
for heart disease such
as history of elevated Disease
blood lipids, smoking,
poor dietary habits, (CAD)
sedentary lifestyle, and Usual Treatments:
obesity. Meds, Vaccinations,
Treatments
• Dietary changes
Nursing Considerations: • Lipid-lowering
Anticipated Nursing
Diagnoses: • Lifestyle changes can drugs.
reverse CAD. • Cardiac
• Risk for decreased catheterization with
cardiac output • Assess shortness of breath
with activity. balloon angiography
• Acute Pain and stent placement,
• Teach patients that CAD
• Risk for Activity may be genetic, but there depending on
Intolerance are modifiable risk factors severity.
• Risk for powerlessness (cessation of smoking, • CABG
• Risk for Imbalanced healthy diet, exercising).
Nutrition
 POC & CONCEPT MAPS WEEK 12 21

Pathophysiology:
Hyperlipidemia is a condition where a group of metabolic
abnormalities of lipoproteins resulting in elevations of fasting
total cholesterol concentration. Lipids are not soluble in plasma
but are transported by the lipoproteins. Primary cause of
hyperlipidemia is genetics including isolated cholesterol
Clinical Manifestations elevation, elevated cholesterol and triglycerides, and isolated
Patient S/S: triglyceride elevation. Secondary cause is diet which includes
satuated and trans fat, excess calories, alcohol, red meat, whole
• Usually asymptomatic milk, and high sugar beverages and foods. Primary risk factor Clinical
until significant target for atherosclerosis, coronary artery disease, and cardiovascular Manifestations Labs
organ damage is done disease. Hyperlipidemia is more common in people with & Diagnostics:
(chest pain, MI; TIA, hypertension. • Elevated serum
stroke). total cholesterol
• May be metabolic signs • Elevated low-
such as corneal arcus, density lipoprotein
xanthoma, xanthelasma, (LDL)
and pancreatitis.
• Elevated
• Intermittent claudication Triglycerides
• Arterial occlusion of Hyperlipidemia • Decreased high-
lower extremities. density lipoproteins
• Complications: Disability (HDL)
from MI, stroke, and
lower extremity ischemia.

Usual Treatments:
Nursing Considerations: Meds, Vaccinations,
• Monitor blood levels for HDL & Treatments
Anticipated Nursing
Diagnoses: LDL. • Lipid-lowering drug therapy
• Assess vital signs, especially BP & (statins).
• Risk for Ineffective auscultate breath sounds. • Lipid-lowering agents: Garlic,
Cerebral Tissue • Assess for PVD. flaxseed, niacin, Omega-3
Perfusion fatty acid, psyllium, plant
• Obtain medical & diet history.
• Ineffective Health sterols, red yeast rice, & soy.
Maintenance • Teach patients the importance of
diet, exercise, & weight loss. • Treatment also includes weight
• Imbalanced Nutrition: loss, decreased dietary fat and
more than body • Encourage patient of smoking
cessation & limiting alcohol. cholesterol intake, & increase
requirements in activity level.
 POC & CONCEPT MAPS WEEK 12 22

Pathophysiology:
Blood pressure is determined by cardiac output, Clinical Manifestations
which is determined by heart rate multiplied by the Labs & Diagnostics:
stroke volume. The heart rate can be affected by
stimulation of the SNS responding to artieral • Creatinine serum or
baroreceptors that measure BP and by plasma
chemoreceptors that measure CO2 levels. Other • Protein, urine
mechanisms that alter BP include renin- • Renal biopsy
angiotensin-aldosterone system, exercise, • Renin, plasma
emotions, and taking meds that cause • Urea nitrogen (BUN),
vasoconstriction. High BP damages the intima of serum or plasma
arteries, making way for infiltration of • Sodium, serum or plasma
macrophages, muscle fibers, cholesterol, and fatty Usual Treatments:
acids that form atherosclerotic plaque. PVR is the • Urine Analysis
Meds, Vaccinations,
resistance to blood flow through arterioles creating Treatments
a high afterload. • Diuretics
• Antihypertensives
• Lifestyle changes
Hypertension • Smoking cessation
Clinical Manifestations program
Patient S/S:
• Systolic BP >139 mm Hg
& Diastolic BP >89 mm Nursing Considerations:
Hg. • Assess BP carefully in the
• Patient may have no correct way with the correctly
symptoms (Silent Killer). Anticipated Nursing sized cuff, the patient seated,
• Most common: Fatigue, Diagnoses: and sphygmomanometer at heart
dizziness, palpitations, • Deficient Knowledge level. Take BP after 5 minute of
angina, & dyspnea. regarding condition, rest.
• In severe cases: headache, therapeutic regimen, & • Teach patients to change
nausea or vomiting, potential odifiable risk factors, avoid
confusion, visual changes complications. added salts, decrease caffeine
or nosebleed. • Risk for decreased intake, drink alcohol
Cardiac Output moderately, take prescribed
• Risk for Activity meds regularly, and manage
Intolerance stress through exercise or
meditative means.
• Acute Pain
POC & CONCEPT MAPS WEEK 12 23

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