Philosophy of Nursing
Nursing is the work of a strong heart guided by an ample mind.
It is the ability to recognize and understand the emotions experienced by another, leading
to a feeling of compassion for their suffering, which in turn, motivates a desire to help the
sufferer. For a nurse, the ability to empathize leads to an intrinsic desire to deliver high quality
nursing care to their patients. This includes outstanding assessment skills, a strong advocacy for
patents, excellent precision and accuracy in care, patience, the ability to carry out orders in a
timely manner, respect, adherence to privacy, being knowledgeable and continuing education,
caring for the ill, and maintaining the fitness of the healthy. The values of empathy and
compassion for another human being at their most vulnerable time are also carried within a
nurse’s care—in really everything they do and say. These values do not falter from outside
factors such as staffing, the number of shifts worked, personal matters, or by the way they
themselves are treated by others. A nurse will always work from the heart, and give the best of
them at all times.
The nursing profession has given me the ability to see the human condition in a way no
other profession can. It has given me a clear understanding and respect for all life; it reminds me
that we all have a purpose, that we all have our own journey. It has given me an abundance of
knowledge and has allowed me to bask in the glory of self-confidence and self-esteem within
myself and my duties. The nursing profession has given me a sense of pride in what I do for
others and a sense of accomplishment that I am able to make a difference in their lives, and as a
result, it has made a difference in my own life and allowed me to accomplish what I never
thought was possible.
For these reasons and many more I own a debt of gratitude to the profession of nursing. A
debt that is paid little by little in my actions as a nurse—the extra time spent with an elderly
patient who needs the company; the patience I show a scared mother with a sick child; the
understanding I give to the fiery patient who has endured a great loss—this is how I repay my
debt to a profession that has given to me so much more than I could ever give back in my
As a child, my mother, who was the director of Nursing at Attleboro Nursing Home,
would take me to work with her on the weekends and I would volunteer. I enjoyed getting water
for and talking with the residents. Being there made me feel a sense of purpose; that what I was
doing made a difference, if even in a small way. I also felt a sense of pride watching my mother
work. She was professional, well-liked, and the smartest person I knew. I told anyone who even
seemed remotely interested that my mom was a nurse. At the time this meant the world to me. So
it would only seem appropriate that when I turned eighteen, I applied for the Nurse’s Aide
training course at Attleboro. I was excited to be accepted into the course and decided it was a
good alternative to attending college, largely because I didn’t think school and I were a good fit
at the time. I had struggled since elementary school with reading and math, and I had never
considered myself intelligent. I felt that I was in no way in the same category as my mom, who I
had watched work for so many years.
I always enjoyed working as a nursing assistant and the time I spent with the people I
cared for. I learned skills that would remain with me for a lifetime; such as a strong work ethic
based on patience and compassion, and the importance of basic care. Three years passed and the
realization set in that the money I was making would never foster my independence or freedom
as a person. I also began to notice the LPN’s at work, and would think to myself—I can do that. I
applied to the LPN program at the Bucks County Technical School and, although I struggled a
bit in the beginning of the program, I excelled in clinical and everything started to fall together.
For the first time in my life I was developing the self-esteem I needed to succeed. I felt
intelligent, and I made a concise decision not to just become a nurse, but to be a great nurse, and
to always work to the best of my ability. When I graduated from the school I had won an award
in Medical-Surgical Nursing. It was my greatest accomplishment.
More and more time went by, and I began to feel like I had not yet lived up to my full
potential. I knew then that it was time to pursue my RN. It had been several years since I had
been in school and the majority of my classmates were much younger than I. At times, this could
be intimidating, but I continued to push forward with the knowledge that this was my true calling
in life. Once again I excelled in all my classes, at times, even to my own amazement. I could not
believe that at one time I thought of myself as unintelligent, or how completely my life had
I credit the nursing profession for developing my self-esteem and character. The time I
spent caring for people has given me a true understanding and compassion for human life. I truly
love what I do and always strive to be an outstanding patient advocate, preform all tasks with a
patient centered focus, and to use my education to make sound, ethical, and independent
decisions consistent with all medical protocols.
SHANNON MARIE CULVER
1440 Center Street, Levittown, PA 19057
Licensed Practical Nurse
Career professional with more than 20 years practical experience in nursing homes,
home health, and rehabilitative care environments.
Established in adult and adolescent disability care, respiratory management,
tracheostomy care, nasopharyngeal suctioning, seizure precautions, G-tube feedings;
care and maintenance. Skilled in assessment, medication administration and wound
Experience with post CVA and neurological assessment. Knowledgeable of various
forms of dementia including providing behavior and emotional support to these
patents. Experienced with IDDM and insulin injections.
Highly experienced in acts of daily living procedures, including skin care, positioning,
feeding, AROM, PROM, and safety.
Patient centered work ethic with independent decision-making ability consistent with
Computer skilled. Proficient in all documentation/record maintenance/paperwork to
ensure accuracy and patient confidentiality.
Licensed Practical Nurse, State of Pennsylvania 1999
Bayada Home Health Care
Licensed Practical Nurse
Responsibilities and duties include:
Adolescent and adult care including:
Tracheostomy care, nasopharyngeal suctioning, CPT, CPAP, Bipap, mini-neb
treatments, pulse oximeter monitoring, cough assist machine and CPT vest use, O2
therapy. Respiratory monitoring and assessment.
Gastrostomy feeding and medication administration; Jejunostomy tube feeding and
medication administration; stoma care. Abdominal assessment.
Monitoring of seizure activity and precautions.
Complete ADL’s and passive range of motion.
Positioning, skin care and assessment, transfer and use of Hoyer Lift.
Intake and output tracking, vital signs, documentation of care.
Pediatric Services of America 9/2006-1/2010
Licensed Practical Nurse
Responsibilities and duties include:
Adolescent care including:
Tracheostomy care, suctioning, CPT, mini-neb treatments, pulse
oximeter monitoring, cough assist machine, PRN O2 therapy.
Respiratory monitoring and assessment.
Gastrostomy feeding and medication administration, Farrell
Valve gastric relief system use and stoma care.
Complete ADL’s, vital signs and passive range of motion.
Positing, skin care and assessment.
Intake and output tracking. Vital signs.
Documentation of care and shift assessment.
Associate, Nursing 2012-2015
Bucks County Community College
275 Swamp Rd, Newtown, PA 18940
Anticipated graduation May 21, 2015; I will sit for the NCLEXRN June 2015
Clinical experience at Aria Torresdale Hospital, Lower Bucks Hospital, Fox Sub Acute, and
Horsham Mental Health Clinic
Practical Nursing Program 1998 -1999
Bucks County Technical School
610 Wistar Rd, Fairless Hills, PA 19030
American Heart Association CPR and AED Certification 6/2014
National Stroke Association Certification 10/2014
IV Certification for LPN’s 3/2001
Certified Nursing Assistant Certification 8/1994
Skills I am proficient at
Skills I need a
first time I perform, or
have not done in a
Skills I need to
improve before I can
NG/G tube insertionandcare
NG/G tube medication
Care of surgical incisionswith
Assessmentandcare of pressure
Care of Drains
Peripheral IV insertion
Basic 12 leadEKG interpretation
Use of Cardiac Monitor
Maintenance of IV's
Administration/mixing IV meds
Care/maintenance of Central
Use of GlasgowComa Scale
Knowledgeof Normal SerumLab
BC, age 72, was admittedtothe ICU on 9/12/2014 forbladdercancerand S/P Cystectomy.On9/14/2014, she was transferredto
BC has a past medical historyof bone spur,DJD,highcholesterol,chemotherapy,HTN,Irritable bowel syndrome,
Upon assessmentBCisalertandorientedtoperson,place,andtime.She isable tofollow commandsappropriately.Pupilsare
equal,round,andreactive tolightandaccommodation;PERRLA.She isable to holdup herupperand lowerextremitiesfora
count of five withoutweaknessortremor,bilateral strength isequal andsensationonherextremitiesisintact.There isnonoted
facial droop,and whenaskedtosmile hermouthwassymmetrical.Verbalizationisclearandunderstandable.She wasable to
recall the wordscat, four,and Decemberafterfive minutes.
T- 97.2, BP- 142/80, P-76 regular,S1 and S2 are audible,RR-16at restand are evenandunlaboredwithsymmetrical chest
DeniesSOBandcough, pulse ox 96% R/A.BC denieschestpainanddyspnea.Bilateral peripheral pulsesare palpable andequal;
there istrace non-pittingedematoheranklesandfeet,and+1 pittingedematoherhands andwrists.She deniescalf
tenderness.Skinispink,warm,anddry.Mucous membranesare pinkandmoist.Nail bedsare pinkandcapillaryrefill iswithin
three seconds.She hasa righthand peripheral IV 22gauge; clean,dry,andintact.Skinaround the site ispinkandshowsno signs
of swelling,infiltration,orphlebitis.Dextrose 5%with0.45% sodiumchloride isrunningcontinuously1000ml@60ml/hr for
hydrationS/P Cystectomy.The antihypertensivemedicationsatenolol (Tenormin;Betablocker) 50mg,andamlodipine(Norvasc;
calciumchannel blocker) 5mgare orderedonce daily.The antihyperlipidemicsimvastatin(Zocor) 20mgisorderedatbedtime for
a historyof highcholesterol. Triamterenehydrochlorothiazide (Dyazide-Maxzide)37.5mg-25mgis a combinationof twodiuretics
usedto treatedemaandhypertension.The antibioticnitrofurantoin(Macrodantin) 100mgoral isorderedforS/P Cystectomy.
The anticoagulantenoxaparininjectable (lovenox) 40mgsubcutaneousdaily isordered forthe preventionof bloodclots,and
polyethylene glycol powder(Miralax) isan osmotic-typelaxative orderedone packettwotimesadayfor constipation.
BC’s Abdomenistenderandnondistended,nopalpationwasperformedasperpatientsrequestandS/P Cystectomy,+BSinall
fourquadrants,and deniesnauseaorvomitingatthistime butreceivedPRN metoclopramideinjectable (Reglan) 10mg an
Antiemetic, Dopamine-2ReceptorAntagonist @4pm on 9/16 for nausea.Reportsabdominal painof 8on a scale of 1-10 but
statedthat itis relievedbyprescribedmedication.Morphine injectable isordered,anarcoticanalgesic,2mgintravenousevery
twohours PRN for severe pain.Oxycodone (Percocet), anarcoticanalgesic,isordered5mg-325mg2 tabletseverysix hoursfor
moderate painandone tableteverysix hoursformildpain.The patienthastwo,twoinchverticle insisionsinthe RLQ.Inboth
inscionsthe edgesare pink,approxamated,andwithoutdischarge.She hasa cystostomyinherRLQ, pinkanddrainingblood
tinged,yellowurine;1000cc output.The patenthas a two anda half inchvertical,midline insiciondirectlyunderherumbilicus.
The edgesare pink,approxamated,andwithoutdrainage.She hasa twoinchLLQ horazontal incision,edgesare pink,
approxamated,andwithdischarge.The patenthasa LLQ JP draincovedbya C/D/Idressing.The drainisdrainingbrightred
blood;180cc output.BChas a C/Ovaginal bleeding;MDnotifiedbyRN,nonew ordersreceived.HMG is8.5 (normal 12-14) MD
BC’s appetite ispoorandonlyconsumed10% of breakfastandlunch. Oral fluidintake was480cc and IV fluidwas600cc. She is
on a regularhouse diet.BCdeniesconstipationandstatedherlastBMwas thismorning. Extremitiesare moveable without
Cardiac and Endocrine Teaching Care Plan
Bucks County Community College
Mrs. Tamblyn, MSN, RN
Table of Contents
Caring Concepts 3
History/Psychosocial information 3-4
Functional Health Patterns 5-7
Nursing Diagnosis 7-13
Medication list 13-18
Abnormal Labs 18-19
The student was aware (Gaut, 1983) that AH has a past medical history of hypertension and Diabetes Mellitus.
The student nurse used knowledge (Gaut, 1983) to educate the patient on why her hypertension and blood glucose
levels need to be monitored, and why taking her medication and regular accuchecks are so important. The student
nurse also used intention (Gaut, 1983) by making sure the patient ordered a diabetic, cardiac diet and by keeping her
blood pressure and blood sugar within normal range. Criterion Welfare (Gaut, 1983) was used by helping the patient
order lunch to keep on the diabetic, cardiac diet that was endorsed for her. The student nurse saw a positive change
(Gaut, 1983) when the patient understood why it was important to maintain her specific diet and accucheck regimen.
AH, age 70, was admitted to the ICU of Aria Health, Torresdale Campus, on 9/12/2014 for an acute
intracerebral hemorrhage. On 9/14/2014, she was transferred to the Stepdown unit, and then to the telemetry unit on
AH has a past medical history of COPD, diabetes, high cholesterol, TIA, HTN, and cervical cancer with
hysterectomy. She was on q2 hour neuro checks and fall precautions due to a change in mental status secondary to the
intracerebral hemorrhage. She was on aspiration precautions secondary to dysphagia. A mechanical soft, 1800 ADA
diet with HS snack was ordered for her. AH reports wearing full upper and lower dentures. AH also reports checking
her blood sugar at home before meals. She was on a telemetry pack (#8643) and a cardiac monitor secondary to HTN
and elevated CPK on admission. AH denied pain and reports being allergic to codeine and penicillin, but stated that she
was unaware of her reaction to these drugs.
AH reported living at home with her son and daughter prior to admission. When asked why she was admitted to
the hospital, she stated, “I think I passed out to tell you the truth.” She would be discharged to Moss Rehab on 9-17-14.
AH denied the use of tobacco, alcohol, and/or drugs. AH stated she is a devote Methodist and uses prayer as a form of
AH was observed sobbing in her room several times throughout the day. When speaking with her about her
medical condition she was anxious and fearful, but also hopeful, stating “prayer helps and I know it will come back.”
AH reported having high self-esteem and her interactions were appropriate. She reported being a retired medical
assistant and enjoyed speaking about her career.
Upon entering the room AH was in bed, her call bell was within reach, and the bed was in its lowest position. T-
98, BP- 140/68, P-60 regular, S1 and S2 were audible, RR-16 at rest and were even and unlabored with symmetrical
chest movements. Breathing sounded vesicular but diminished throughout the upper lobes and right lower lobe with no
crackles; slight wheeze to lower left lower lobe. Denied SOB and cough, pulse ox 96% R/A. AH denied chest pain and
dyspnea. The ECG on 9/17/14 showed sinus bradycardia and a HR of 58. Bilateral peripheral pulses were palpable and
equal, there was trace non-pitting edema to her ankles and feet, she denied calf tenderness. Skin was pink, warm, dry,
and intact. The skin on her lower extremities was blotchy brown from the ankles to mid-calf. Affected lower
extremities were warm and moveable. Mucous membranes were pink and moist; lips were dry. Nail beds were pink and
capillary refill was within three seconds. She has a left hand peripheral IV 22 gauge; clean, dry, and intact. Upon
inspecting, the skin around the site was pink and showed no signs of swelling, infiltration, or phlebitis. AH’s abdomen
was soft, non-tender, and non-distended; denied pain with palpation, +BS in all four quadrants. Denied nausea or
vomiting after meals and there was no recorded use of PRN ondansetron injectable (Zofran) for nausea or vomiting.
AH ate 100% of breakfast and lunch, but reported having trouble swallowing at times and was ordered a mechanical
soft diet. She receives accuchecks QID before meals with sliding scale insulin coverage secondary to diabetes: 7am BS
– 162; covered with 2U of regular insulin by night shift. 11am BS – 131; no coverage required. 1600 BS – 104; no
coverage required. AH denied constipation and stated that her last BM was on 9/16/14. AH is able to empty her bladder
and denied burning, dysuria, or pain. Bladder was not distended after urination; urine was clear and yellow. AH voided
three times with assistance to the commode. Extremities are moveable without limitation and no joint swelling was
Functional Health Patterns
The Health Perception Pattern analyzes the patient’s knowledge of their past medical history and admitting
diagnosis. The nurse assesses objective information such as vital signs and gains subjective information about health
practices. It was determined that this pattern was ineffective in AH’s assessment, evidenced by the patient’s lack of
knowledge about her disease processes and the long term effects of high blood pressure and unstable blood glucose
levels; Nursing Diagnoses: Knowledge Deficit (Ackley, 2014 page 504-507). In the Nutrition/Metabolic Pattern, the
nurse assesses appetite, weight, swallowing, dentures, skin, mucus membranes, diet, and fluid (PO and peripheral). It
was determined that this pattern was ineffective in AH’s assessment, evidenced by obesity, diabetes mellitus, impaired
swallowing, discoloration and edema to lower extremities. Nursing diagnoses: Imbalanced Nutrition: more than body
requires (565-569), risk for unstable blood glucose level (386-390), impaired swallowing (792-797), ineffective
peripheral tissue perfusion (810-815). The Elimination Pattern monitors a patient’s output. The nurse performs an
abdominal assessment and makes note of and checks the patency of any appliances that are needed for output. It was
determined that this pattern was effective in AH’s assessment, evidenced by patient reports of regular bowl movements
and urination three times by the end of the shift. The Activity/ Exercise Pattern assesses areas such as self-care ability,
assistive devices, activity intolerance, ROM, heart sounds, peripheral pulses, and respiratory. It was determined that
this pattern was ineffective in AH’s assessment, evidenced by use of a walker, unstable gait, fall precautions, history of
hypertension, and presence of wheeze and diminished lung sounds. Nursing diagnoses: Impaired physical mobility
(536-542), risk for falls (332-337), decreased cardiac output (179-186), and risk for activity intolerance (125-128). The
Sleep/Rest Pattern assesses the sleep habits and use of sleep aids. It was determined that this pattern was potentially
ineffective in AH’s assessment, evidenced by the patients statement, “I sleep for five hours a night and wake up early.”
Nursing diagnoses: Disturbed sleep pattern (746-748). The Cognitive/Perceptual Pattern assesses mental status,
hearing, vision, speech, orientation, wandering, and pain. It was determined that this pattern was ineffective in AH’s
assessment, evidenced by aphasia. Nursing diagnosis: impaired verbal communication (220-225). The Self-
Perception/Self Concept Pattern assesses body image, self-esteem, appropriateness, and emotional status. It was
determined that this pattern was ineffective in AH’s assessment, evidenced by increased levels of anxiety and fear.
Nursing diagnosis: Anxiety (137-141), Fear (353-356). The Role Relationship Pattern assesses the patient’s support
system, occupation, and developmental level. It was determined this pattern was effective in AH’s assessment,
evidenced by the patient’s statement, “I live with my son and daughter...I have a good relationship with them” and her
speaking very fondly of being a retired medical assistant. AH stated she was happy with the life she lived and was not
afraid to die. According to Erikson’s Theory of Psychosocial Development, a person of AH’s age is in the Integrity vs.
Despair stage of development. In this phase a person looks back on their life, and if one is satisfied with their
accomplishments, they are able to develop integrity (About.com 2014).
The Sexuality/Reproductive Pattern assesses a patient’s menstrual history, history of mammograms, birth control,
hormone replacement, and sexual concerns regarding illness. It was determined that this pattern was effective in AH’s
assessment, although the patient underwent a hysterectomy she reported having two children and a “loving”
relationship with her late husband. The Coping/Stress Tolerance Pattern assesses major concerns regarding
hospitalization and illness. It was determined this pattern was effective in AH’s assessment, evidenced by the patient’s
statements of being “hopeful” and finding strength in prayer. Nursing diagnosis: Readiness for enhanced hope (420-
422). The Value/Belief Pattern assesses religious or cultural practices that may be affected by hospitalization. It was
determined this pattern was effective in AH’s assessment, evidenced by stating she is a practicing Methodist. She
reported no religious practices that have been affected by her hospitalization. She is not an organ donor due to her own
preference. Nursing diagnosis: Readiness for enhanced spiritual well-being. (765-768)
Cardiac Nursing Diagnosis
Diagnosis- DecreasedCardiac output (Ackley, 2014 page 179-186)
Patient goals (short term) - By the end of shift, patient will maintain blood pressure within her individually acceptable
Patient goals (long term) - By the time of discharge the patient will verbalize an understanding of why it is important
to maintain a blood pressure within her individually acceptable range.
(1) Monitor blood pressure/vital signs.
(2) Auscultate heart and breath sounds.
(3) Observe skin color, moisture, temperature, and capillary refill time.
(4) Note dependent and/or general edema.
(5) Administer medications as indicated.
Rationale for Interventions
(1) Comparison of pressures provides a more complete picture of vascular involvement and scope of problem.
(2) S4 heart sound is common in severely hypertensive patients because of the presence of atrial hypertrophy (increased
atrial volume and pressure). Development of S3 indicates ventricular hypertrophy and impaired functioning. Presence
of crackles or wheezes may indicate pulmonary congestion secondary to developing or chronic heart failure.
(3) Presence of pallor; cool, moist skin; and delayed capillary refill time may be due to peripheral vasoconstriction or
reflect cardiac decompensation and decreased output.
(4) May indicate heart failure, renal or vascular impairment.
(5) Administering medication will help keep blood pressure down allowing the body to recover, and possibly
preventing the consequences of long term, uncontrolled high blood pressure.
Short Term- This goal was met throughout the shift and the patient’s blood pressure remained within normal limits.
Long Term- This goal was also met. Patient verbalized understanding in maintaining a blood pressure within her
individually acceptable range.
Diagnosis- Knowledge deficit (Ackley, 2014 pages 504-508)
Patient goals (short term) - Upon the end of the shift, patient will have an understanding of her disease process and
why dietary and medication compliance is important.
Patient goals (long term) - Patient will comply with diet and medication regimen.
(1) Assess readiness and blocks to learning.
(2) Define and state the limits of desired BP. Explain hypertension and its effects on the heart, blood vessels, kidneys,
(3) Assist patient in identifying modifiable risk factors, e.g., obesity; diet high in sodium, saturated fats, and
cholesterol; sedentary lifestyle; smoking; alcohol intake (more than 2 oz/day on a regular basis); stressful lifestyle.
(4) Problem-solve with patient to identify ways in which appropriate lifestyle changes can be made to reduce
modifiable risk factors.
(5) Reinforce the importance of adhering to treatment regimen.
Rationale for Interventions
(1) If patient does not accept the reality of a life-threatening condition requiring continuing treatment, lifestyle and
behavioral changes will not be initiated or sustained.
(2) Provides basis for understanding elevations of BP, and clarifies frequently used medical terminology.
Understanding that high BP can exist without symptoms is central to enabling patient to continue treatment, even when
(3) These risk factors have been shown to contribute to hypertension, cardiovascular and renal disease.
(4) Changing comfortable and usual behavior patterns can be very difficult and stressful. Support, guidance, and
empathy can enhance patient’s success in accomplishing these tasks.
(5) Lack of cooperation is a common reason for failure of antihypertensive therapy. Therefore, ongoing evaluation for
patient cooperation is critical to successful treatment. Compliance usually improves when patient understands causative
factors and consequences of inadequate intervention and health maintenance.
Short term- This goal has been met. The patient verbalized understanding of her disease process, and why dietary and
medication compliance is important.
Long term- This goal will remain in progress upon discharge to Moss Rehab.
Endocrine Nursing Diagnosis
Diagnosis- Risk for unstable blood glucose levels (Ackley, 2014 page 386-390)
Patient goals (short term) - By the end of the shift, patient will maintain blood glucose level within normal limits.
Patient goals (long term) - By the time of discharge, patient will verbalize understanding of why it is important to
maintain a blood glucose level within normal limits.
Nursing Interventions –
(1) Monitor blood glucose levels before meals and as needed as ordered.
(2) Monitor for signs and symptoms of hypoglycemia, such as shakiness, dizziness, sweating, hunger, headache, pallor,
behavior changes, confusion, or seizures.
(3) Monitor for signs and symptoms of hyperglycemia, such as increased thirst or urination, and high blood glucose
(4) Monitor fluids and carbohydrate intake.
(5) Administer oral hyperglycemic medications and sliding scale insulin as indicated.
Rationale for Interventions
(1) Blood glucose monitoring before meals and as needed prevents hypo/hyperglycemia.
(2) Hypoglycemia must be treated quickly to prevent loss of consciousness.
(3) Early recognition and treatment of hyperglycemia can prevent progression to ketoacidosis or Hyperosmolar
Hyperglycemic Non-Ketotic Syndrome.
(4) Aids in the prevention of hypo/hyperglycemia.
(5) Administering medication will help keep blood glycose levels within normal limits and possibly prevent the
consequences of long term, uncontrolled high blood glucose.
Short Term- This goal was met. Throughout the shift the patient’s blood glucose remained within normal limits.
Long Term- This goal was met. Patient verbalized understanding of why it is important maintaining a blood glucose
level within normal limits.
Diagnosis- Ineffective peripheral tissue perfusion (Ackley, 2014 page 810-815)
Patient goals (short term) - By the end of shift, patient will demonstrate adequate tissue perfusion evidenced by
palpable peripheral pulses, warm dry skin, adequate urine output, and absence of respiratory distress.
Patient goals (long term) - By the time of discharge the patient will verbalize understanding of appropriate exercises to
increase peripheral tissue perfusion.
(1) Check the brachial, radial, dorsalis pedis, posterior tibial, and popliteal pulses bilaterally.
(2) Assess for pain in the extremities.
(3) Note skin color and feel temperature of skin.
(4) Check capillary refill.
(5) Note the presence of edema in the extremities and rate severity on a four point scale.
Rationale for Interventions
(1) Diminished or absent peripheral pulses indicates arterial insufficiency with resultant ischemia.
(2) In patients with venous insufficiency, the pain lessens with elevation of the legs and exercise. In patients with
arterial insufficiency, the pain increases with elevation of the legs and exercise.
(3) Skin pallor or mottling, cool skin temperature, or an absent pulse can signal arterial obstruction. Rubor indicates
dilated or damaged vessels. Brownish discoloration of the skin indicates chronic venous insufficiency.
(4) A capillary refilling time greater than three seconds is abnormal.
(5) Edema in the extremities indicates a buildup of fluid in the tissues and decreases peripheral profusion.
Short Term- Patient was moderately compromised, evidenced by brownish coloration and trace edema to lower
Long Term- This goal was met. Patient verbalized understanding of leg exercises she can do while in bed and sitting in
dexamethasone injectable (Decadron): steroidal anti-inflammatories; glucocorticoids
Action: suppresses inflammation and the normal immune response.
Indications: used systemically and locally in a wide variety of chronic diseases
Side effects: depression, euphoria, hypertension, peptic ulceration, decreased wound healing, adrenal suppression,
thromboembolism, osteoporosis, and cushingoid appearance.
Nursing implications: assess for signs of adrenal insufficiency, monitor I and O and daily weights, assess for a change
in LOC and headache, assess symptoms of ulcerative colitis, and monitor serum electrolytes and glucose.
levetiracetam (Keppra): anticonvulsants; pyrrolidines
Action: inhibits burst firing without affecting normal neuronal excitability.
Indications: Partial onset seizures, primary generalized tonic-clonic seizures, myoclonic seizures in patients with
juvenile myoclonic epilepsy.
Side effects: aggression, agitation, anger, apathy, depersonalization, depression, dizziness, personality disorder,
weakness, Stevens- Johnson syndrome, and toxic epidermal necrolysis.
Nursing Implications: assess for seizure activity, assess for CNS adverse effects throughout therapy, monitor for mood
changes and rash. Keppra may cause a decrease in RBC and WBC and abnormal liver function tests.
enalapril (Vasotec): antihypertensive; ACE inhibitor
Action: blocks the conversion of angiotensin 1 to the vasoconstrictor angiotensin 2.
Indications: management of hypertension, symptomatic heart failure, and slowed progression of asymptomatic left
ventricular dysfunction to overt heart failure.
Side effects: cough, hypotension, taste disturbances, agranulocytosis, and angioedema.
Nursing implications: include monitor BP and pulse, assess for signs of angioedema, monitor weight, monitor kidney
and liver lab values, and electrolyte levels.
simvastatin (Zocor): Antihyperlipidemics; hmg coa reductase inhibitors (statin)
Action: Inhibits 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase.
Indications: Adjunctive management of primary hypercholesterolemia and mixed dyslipidemias.
Side effects: abdominal cramps, heartburn, altered taste, drug-induced hepatitis, dyspepsia, ↑ liver enzymes,
Nursing implications: instruct patient to take medication as directed, not to skip doses or double up on missed doses.
Advise patient to avoid drinking more than 1 qt of grapefruit juice/day during therapy. Instruct patient to notify health
care professional if unexplained muscle pain, tenderness, or weakness occurs, especially if accompanied by fever or
ezetimibe (Zetia): lipid-lowering agents; cholesterol absorption inhibitors.
Action: Inhibits absorption of cholesterol in the small intestine.
Indications: management of dyslipidemias.
Side effects: cholecystitis, cholelithiasis, ↑ liver enzymes (with HMG-CoA reductase inhibitors), nausea, pancreatitis,
Nursing implications: evaluate serum cholesterol and triglyceride levels before initiating, after 2–4 wk of therapy, and
periodically thereafter. Monitor liver enzymes prior to initiation of drug therapy and during.
ondansetron injectable (Zofran): antiemetic; five ht3 antagonists
Action: blocks the effects of serotonin at 5-HT3–receptor sites.
Indications: Prevention and treatment of postoperative nausea and vomiting.
Side effects: Headaches, dizziness, QT interval prolongation, abdominal pain, dry mouth, ↑ liver enzymes, and
Nursing implications: Assess patient for nausea, vomiting, abdominal distention, and bowel sounds prior to and
following administration. Assess patient for extrapyramidal effects. Monitor ECG in patients with hypokalemia,
hypomagnesaemia, HF, bradyarrhythmias, may cause transient ↑ in serum bilirubin, AST, and ALT levels.
glipizide (Glucotrol): antidiabetics; sulfonylureas
Action: Lowers blood sugar by stimulating the release of insulin from the pancreas and increasing the sensitivity to
insulin at receptor sites.
Indications: Controls blood sugar in type 2 diabetes mellitus when diet therapy fails.
Side Effects: dizziness, drowsiness, headache, weakness, drug-induced hepatitis, dyspepsia, photosensitivity, rashes,
Nursing implications: Observe for signs and symptoms of hypoglycemic reactions (sweating, hunger, weakness,
dizziness, tremor, tachycardia, anxiety). Patients on concurrent beta-blocker therapy may have very subtle signs and
symptoms of hypoglycemia.
metformin (Glucophage): antidiabetics; biguanides
Action: Decreases hepatic glucose production, intestinal glucose absorption, and increases sensitivity to insulin.
Indications: Management of type 2 diabetes mellitus; may be used with diet, insulin, or sulfonylurea oral
Side Effects: abdominal bloating, unpleasant metallic taste, lactic acidosis, and decreased vitamin B12 levels.
Nursing implications: When combined with oral sulfonylureas, observe for signs and symptoms of hypoglycemic
Regular insulin (Humulin R): antidiabetics; pancreatics
Action: Lowers blood glucose by stimulating glucose uptake in skeletal muscle and fat, and inhibiting hepatic glucose
Indications: Control of hyperglycemia in patients with diabetes mellitus.
Side Effects: hypoglycemia, lipodystrophy, pruritus, erythema, swelling, and anaphylaxis.
Nursing implications: Assess patient periodically for symptoms of hypoglycemia, Monitor body weight periodically.
Changes in weight may necessitate changes in insulin dose. Monitor blood glucose every 6 hr during therapy, more
frequently in ketoacidosis and times of stress. A1C may be monitored every 3–6 mo to determine effectiveness.
CPK- elevated on admission. CK-1 (BB) is produced primarily by brain tissue and may be elevated with shock, brain
tumors, or severe cerebral accidents (Pearson, page 282-284)
Blood sugar- 201 mg/dL on admission (norm.80-120 mg/dL). A blood glucose level greater than 200mg/dL is
considered indicative of diabetes (Pearson, page 183-187).
BUN 31mg/dL (norm.7-18mg/dL) an increase in blood urea nitrogen is indicative of diseased or damaged kidneys
because they are less able to rid the blood of the waist product urea (Pearson, page 83).
WBC; Monocytes 11.7% (4.5-11.0%) Monocytes act as phagocytes in some inflammatory diseases (Pearson, page
55). An increase suggests an inflammatory process.
WBC; Neutrophil 88.3% (40-70%) Neutrophils are the bodies’ first defense against bacterial infection and severe stress
(Pearson, page 55). An increase suggests a bacterial infection or stress on the body S/P intracerebral hemorrhage.
WBC; Lymph 7.4% (22-44%) Lymphocytes are the principal component of the body’s immune system. A marked
increase in Neutrophils always causes a decrease in Lymphocytes (Pearson, page 55).
RDW 15.3% (11.5-14.5%) The Red Blood Cell Distribution Width helps to differentiate between different types of
anemia and their causes (Pearson, page 35). This increase is most likely due to loss of blood S/P intracerebral
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