Running head: Displacement of Lumbar Intervertebral Disc Without Myelopathy 1mriedy.yolasite.com/resources/gero process paper.pdf · · 2011-12-05Running head: Displacement of Lumbar

Running head: Displacement of Lumbar Intervertebral Disc Without Myelopathy 1

Geriatric Patient Nursing Process Paper

Megan Lynn Riedy

Kent State University College of Nursing

DISPLACMENT OF LUMBAR INTERVETEREBRAL DISK WITHOUT MYELOPATHY 2

Introduction

C.C., an eighty two year old female with an admitting diagnosis of displacement of

lumbar intervertebral disk without myelopathy, was assigned to me for care on October 4th

, 2011.

In addition to the displaced lumbar disk, C.C. had a history of diabetes, osteoarthritis and

hypertension. The clinical shift included regular vital signs, head to toe assessments, medication

administration, and all appropriate charting in regard to the care given. Also, various teaching

opportunities were utilized where applicable, and helpful to C.C.’s wellness.

Patient Profile

C.C. was admitted to Altercare of Noble’s Pond, for treatment of a displaced lumbar disc.

C.C. was one of two patients I cared for during the clinical day. Prior to the clinical shift I was

given C.C’s medical cardex including her scheduled and as need medication, and her treatment

flow sheet. From this I was able to gain a basic understanding of what C.C.’s needs may be

throughout the day. After gathering the necessary background data and listening to report I

entered C.C.’s room to meet her and preform a complete assessment.

C.C.’s assessment showed her vital signs to be as followed: Temperature 99.3 F, pulse

72, respiration 14, blood pressure 144/74, and oxygen saturation of 97% o room air. C.C. denied

any pain so long as she wasn’t moving. She was alert and oriented to the person place time and

situation. Her attitude was pleasant and positive. Her skin felt warm and dry and was intact.

C.C.’s speech was clear, pupils were round equal and reactive to light. C.C. showed good range

of motion with strong and equal hand grasps and leg strength. C.C.’s respiratory rate and rhythm

was regular with clear inspiration and expirations in all lobes. Bowel sounds were present in all

four quadrants. Abdomen was soft round and non-distended. C.C. presented with no edema, and

was able to ambulate independently with the use of a walker to use the bathroom.


Next, I preformed a fall risk assessment on C.C.. The “Hendrich II Fall Risk Modle”

assesses the patient’s factors which contribute to falls. In the first half of the test C.C. scored a

zero, as she did not meet any of the criteria which would increase her score. For the second half

of the test C.C. was assessed in her ability to get out of bed. This portion of the test is referred to

as the “Get Up and Go Test”. C.C. was able to rise in one single movement with no assistance.

This indicates a score of 1. The zero from the first portion of the test is added to the 1 from the

second portion of the test. C.C.’s total score is a 1. A score of a five or above indicates a fall

risk according to the test. However, given C.C.’s pain during movement and orders for analgesic

narcotics my care for her still included careful monitoring and fall risk precautions

(Talboski,2009).

Then, a Braden skin assessment was performed on C.C. in order to assess her risk of

developing skin breakdown. C.C.’s sensory perception was not impaired. She was occasionally

moist. C.C. walks occasionally for short distances. She has slightly limited mobility. Her

nutrition is probably inadequate as she eats only about one half of her meals. There appears to

be no problem with friction and shear, as she is able to move in bed and in chair independently.

These aspects of the Braden scale add up to a 20 out of a possible 23. A score of a 16 or less is

an indication of a pressure sore risk and thus needs prevention plan to be implemented.

(Tabloski, 2009)

Lastly a mini mental exam was performed on C.C. This exam required her demonstrate a

knowledge of her orientation, location, and the current time. She was also asked to demonstrate

the ability to name simple ordinary objects such as a pencil and to repeat a series of words. Then

C.C. was asked to draw a simple picture. The test is comprised of several categories which are


scored independently. The total possible points is 30. C.C. scored 30 points on her mini mental

exam. (Tabloski, 2009)

Admitting Medical Diagnosis

C.C. was admitted to Altercare of Noble’s pond due to a displacement of a lumbar

intervertebral disk without myelopathy. C.C.’s chief complaint was of a severe pain in the

lumbar region of her spine when she ambulated. C.C. stated that the pain had been ongoing for

several weeks and had become worse as time progressed.

Pathophysiology of Displaced lumbar Intervertebral Disk

Vertebrae are separated and cushioned by pads of cartilage call intervertebral discs. The

Intervertebral discs have a tough outer layers are called the annulus fibrous. The collagen fiber

of this layer, attach the disc to the adjacent vertebrae. Inside the annulus fibrous is the nucleus

pulpous. This is a soft cushion like area which is able to absorb shock and allow for movement

of the vertebral column. However, when too much pressure compresses the nucleus pulpous, it

can be displaced. (Black & Hawks, 2009)

As patients age the water content of the nucleus pulpous in each sick decreased. They

then become less cushion-like and the chances of a vertebral injury are increased. Also with

advanced age the ligament holding the vertebrae in place become weakened. The compressed

nucleus pulpous may distort resulting in the displacement of the lumbar intervertebral disk. This

often compresses on nerved which are passing thought the adjacent area. The compressed nerve

can produce pain or even myelopathy for the patient. C.C. did no experience any myelopathy.

However she did complain of pain when she was ambulating (Tabloski, 2009).

Clinical Manifestations


Common symptoms include pain while sitting standing walking or bending. The patient

may present a less then normal curvature of the lumbar area of the hip known as Lordosis.

Spinal strength and flexibility is often decreased. Diagnosis can be made by imaging such as a

magnetic resonance image (MRI).

Other Medical Diagnosis

C.C.’s additional medical history included hypertension, constipation, and diabetes. For

C.C., the hypertension was still being controlled with pharmaceutical interventions.

Constipation was controlled with diet, ambulation, and laxatives as needed. C.C.’s Anxiety was

controlled with The diabetes was controlled with diet and an oral antidiabetic medication.

Pathophysiology of Hypertension

Hypertension or high blood pressure, is a common condition in which the force of the

blood against the artery walls is higher than the defined normal. This can cause health problems,

such as heart disease. Hypertension often develops over time. Thus eventually, uncontrolled

and or undiagnosed hypertension will increase a patient’s risk of myocardial infarctions (MIs ) or

stroke (Black & Hawks, 2009).

Clinical manifestations of Hypertension

Many patients will not experience any signs or symptoms of elevated blood pressure.

However, some will experience a dull headache, or dizziness. The most significant/reliable

finding is a regularly elevated blood pressure assessment (Black & Hawks, 2009)

Pathophysiology of Constipation

Constipation is defined s an infrequent defecation, a hardened stool and or a sensation of

incomplete evacuation of bowel movements. Many factors can contribute to constipation such as


dehydration, side effects of medications, and immobility. C.C. likely suffered from constipation

s a result of each of the aforementioned contributing factors (Tabloski, 2009).

Clinical manifestations of Constipation

Constipation results in hard stool. Hard stool is more difficult to pass. Thus, a

complication of constipation can be a fecal impaction which may result in other gastro intestinal

problems. Additionally, excessive straining to pass stool result in hemorrhoids, anal fissures, or

rector prolapse (Tabloski, 2009).

Pathophysiology of Diabetes

The hormone insulin is responsible for maintaining glucose levels in the blood. Insulin

allows the body tissue to use glucose as an energy source. However, in a diabetic patient,

glucose metabolism is compromised as a result in abnormal insulin metabolism. The result is an

increase in circulating blood glucose which can lead to severe complications including

cardiovascular disease kidney damage, nerve problems, and tissue and vision disorders (Black &

Hawks, 2009).

Clinical Manifestations of Diabetes

As a result of increased blood glucose levels, polyuria, polyphagia, glycosuria,

hyperglycemia, and an increase of specific gravity of urine are often clinical manifestation

leading to a diabetes diagnosis. Treatment includes a consistent carb diet and often use of insulin

analog replacement therapy. Hypoglycemia can result from ingesting too little carbohydrates or

taking too much insulin therapy. These symptoms include diaphoresis, confusion, and headache.

Both hyper and hypoglycemic episodes are to be monitored and assessed (Black & Hawks,

2009).

Surgical History


C.C. has currently had one surgery in her lifetime. At 20 years old she described being

sick for a few weeks. C.C. stated that her doctors at the time worried she had tuberculosis, but

later discovered that she did not. As a result of the prolonged illness she eventually had her

tonsils removed later that year.

Gordon’s Function Assessment

AREA OF HEALTH SUBJECTIVE

DATA

OBJECTIVE

DATA

INDIRECT

DATA

*Identify source

of indirect data

INTERPRETATI

ON

(effective

patterns or

barriers/potential

barriers)

HEALTH/PERCEPT

ION

HEALTH

MANAGEMENT General Survey,

perceived health

& well-being, self-

management

strategies, utilization

of

preventative health

behaviors

and/or services.

Pt states she

remains active

and enjoys her

retirement.

Pt describes

herself as

“otherwise

totally healthy

and normal’.

she describes

this with the

exception of

back pain

Vital Signs:

Respirations 14

and unlabored,

pulse 72, temp

99.3°F, pulse

ox 97% on

room air, BP

144/70

Pt is well

groomed

wearing

personal

clothing from

home

Pt is in good

spirits, and

interacts well

with staff.

Pt spends much

time in the

bathroom

applying make

up, lotion, and

perfume

Pt has a history

of displaced

lumbar sick, type

II diabetes and

hypertension

(chart)

Pt.’s current

medications are

as follows

(information

form chart):

Lisinopril

40mg/day

Proprandol hcl 80

mg/day

Ambien 5 mg

PRN po

Acetaminophen

650mg Q6H PRN

Miralax

17gr/dose BID

C.C. seems to

have her health

perception and

management

under control.

She keeps up

with her

physician on an

annual basis .

She seemed to

understand the

importance of

taking good care

of her health and

avoids

environments

which may be

hazardous to her

health or safety.

She makes

attempts to be

careful not to

injures her back

any more.


Precose

25mg/day

Ocycodone ER

20mg BID

NUTRITIONAL/

METABOLIC

Patterns of food and

fluid consumption,

Weight, skin turgor.

(Skin, Hair, Nails;

Head & Neck;

Mouth, Nose, Sinus;

swallowing, Ht., Wt)

Patient states, “ I

am not that

hungry”

pt. states “I like

to drink the

ensure drinks,

they keep me

full, when I

don’t want to eat

the food here”

Pt states “I make

sure at home to

maintain a good

diet because of

the diabetes and

blood pressure”

During shift pt.

drank one 8oz

ensure

Braden skin

scale score

20/23

Skin turgor

was less than

three seconds,

skin was dry

and warm with

good pallor,

Oral cavity was

moist and pink,

pt. has dentures

Pt is 5’2, 180

lbs.

Pt is able to

demonstrate

good mouth

care

Contestant carb

diet (chart)

Medical history

of diabetes and

hypertension

indicate the need

for controlled diet

(chart)

C.C.

demonstrates

knowledge of

nutritional needs.

However, C.C.

has a potential

nutritional deficit

due to her poor

appetite. The

may be related to

pain associated

with ambulation

to the dining

room for meal

time.

ELIMINATION

Patterns of excretory

function &

Elimination of waste;

relevant labs,

Pt states “my

last BM was

yesterday”

Pt states that the

Abdomen soft

symmetrical

and non-

distended,

bowel sounds

Pt has occasional

problems with

constipation.

(chart)

C.C had several

factors

contributing to

her constipation

including

medications


Medications,

impacting, etc.

(Abdominal - bowel

and bladder)

laxatives have

helped her go to

the bathroom a

lot more

Pt states that she

voids about five

to eight times

every day

without pain or

difficulty.

regular in four

quadrants pt.

denies pain

with palpation

Pt up ad lib

independently

(chart)

decreased

ambulation, and

decreased

hydration.

However, no

further problems

from constipation

appear to be

present at this

time.

ACTIVITY/EXERCI

SE Patterns of exercise &

daily living,

self-care activities

include major

body systems

involved.

(Thoracic & Lung;

Cardiac;

Peripheral vascular;

Musculoskeletal,

vital signs)

Pt states “ at

home I live by

myself and care

for myself”

Pt states “I have

a small dog and

care for her by

myself”

Pt explains that

her daughter

helps her do her

grocery

shopping but

requires not

extra help aside

from grocery

shopping while

at home

Currently pt

expresses pain

when

ambulating

Heart sounds

were regular

lung sounds

clear in all

lobes

Lower

extremities are

free of redness

or pain

Range of

motion is

within normal

limits, pedal

pulses were

found to be +2

and equal

bilaterally

Patient was

able to

ambulate with

walker without

assistance to

bathroom and

in hallway 50

feet

Get up and go

test score 1

Patient is up at lib

with walker

(chart)

C.C. is able to

move and care

for herself as she

normally would

with the

exception that she

is in pain when

she moves around

a great deal.


SEXUALITY/

REPRODUCTION Satisfaction with

present level of

Interaction with sexual

partners

(Breast; Testes;

Abdominal-

Genitourinary-

reproductive)

Pt states “I kept

up with my early

pap smears

before, when I

was younger”

Not fully

assessed

Found no

information

regarding

sexuality from

chart

Not fully

assessed

SLEEP/REST Patterns of sleep, rest,

relaxation,

fatigue

(Appearance,

behavior)

Pt states “I

normally sleep

just fine, but

here someone

comes to bother

me”

Pt states “ I can’t

sleep as well

here as I do at

home”

During shift pt.

seemed in good

spirits but with

moderate

fatigue

Pt is on Ambien

10mg daily as

needed before

bed. (chart)

C.C. is in good

spirits and seems

to have a good

amount of

energy, however

after listening to

her normal

activities it

appears she

normally has an

above average

amount of

energy. Her

current state is of

decreased energy

compared to her

normal level.

COGNITIVE/

PERCEPTUAL Patterns of thinking &

ways of

Perceiving

environment,

orientation

Mentation, neuron

status, glasses,

Hearing aids, etc.

Pt. was able to

describe herself,

surrounding, and

situation very

explicitly

Pt describes pain

as a 3 out of 10

and as a dull

pain in her lower

back when

A and O x4

person place

time situation

30/30 on mini

mental exam

Pupils equal

and reactive

Charting

indicates pt. has

regularly been

alert and oriented

Charting

indicated pt has

been medicated

for pain with in

several hours of

assessment time

C.C. does not

appear to have

any cognitive

impairment or

any reason for a

cognitive

impairment

Pain is an

important

manifestation to

assess for C.C. as

this is her chief


moving. Does not use

hearing aid

Wears glasses

Pt’s hand

grasps and leg

strength were

strong and

equal

bilaterally

complain in

regard to her

admitting

diagnosis

ROLE/RELATIONS

HIP Patterns of

engagement with

others,

Ability to form &

maintain meaningful

Relationships,

assumed roles;

Family

communication,

response,

Visitation, occupation,

community

involvement

Pt states “I live

alone with my

dog”

Pt was married

for twenty years,

divorced for

over 40 years

ago

Pt spoke about

her children

stating she has

one daughter

who live nearby

and one son who

“lives faraway”

Pt showed a

positive

attitude toward

her recovery.

She remained

smiling and

comfortable

while talking

about her

family and

support system

Pt ordered to be

up adlib with

walker (chart)

Pt has been in

care facility for 4

days(chart)

C.C. is a

generally very

active and

independent

person. She is

able to keep a

relationship with

her children

although she does

seem to want to

rely on them too

much for help

with her health.

SELF-

PERCEPTION/

SELF-CONCEPT Patterns of viewing &

valuing

Self; body image &

psychological

state

Pt states “ I am

happy with my

life”

During head to

toe assessment

pt. asked

questions

regarding his

vitals in an

effort to know

her continuing

status

Previously A and

O x4 (chart)

C.C. shows signs

of a positive body

image and

psychological

state despite

being slightly

frustrated at her

current loss of

independence

COPING/STRESS

TOLERANCE Stress tolerance,

Pt states “id

rather be at

home”

Pt appeared to

be smiling and

have a positive

Pt had no ordered

medications for

depression or

C.C. appears to

be coping and in

control of stress.


behaviors, patterns

of coping with

stressful events &

level of effectiveness,

depression,

anxiety.

Pt states “I don’t

like taking too

much

medication, I

don’t feel right

when I do”

outlook on her

current state of

wellbeing

anxiety (chart) She currently

appears to only

be bothered by

her pain and her

feeling f loss of

control when

heavily

medicated for

pain.

VALUE/BELIEF Patterns of belief,

values,

Perception of meaning

of life that

guide choices or

decision; includes

but is not limited to

religious beliefs

C.C reports she

is religious, but

she does not

attended church

regularly

A religious get

well card was

observed in the

pt.'s room

Pt chart states she

is Catholic

C.C. seems to

have a personal

relationship with-

in a Christian

belief system.


Laboratory Information

(Normal male values taken from Craven & Hirnle, 2008)

Laboratory Test Normal Values Patient’s Values Interpretation

WBC 5,000-10,000/mm3

4,700/mm3

Low

RBC 4,700,000-6,100,000/mm3 3,880,00/mm

3 Low

Hemoglobin 13.5-19 g/dL 9.4 g/dL Low

Hematocrit 38-47% 34% Low

Sodium 135-145mEq/L 136 Normal

Potassium 3.5-5.0 mEq/L 3.6 Normal

Chloride 95-105 mEq/L 105 Normal

Glucose 70-110 126 High

BUN 5-20mg/dL 12 Normal

Creatinine 0.5-1.3mg/dL 1.1 Normal

Laboratory Information Interpretation

The reason for the white blood cells to be decreased could be due to osteoarthritis.

Tabloski, states that patients with osteoarthritis may have a low WBC associated with the

pathophysiology. Based on C.C.s advanced age, and lumber displacement, this could be a

contributing factor (Tabloski, 2009).

Low RBC could be a result of many different pathogenic reasons including iron

deficiency, vitamin B6, B12, and/or folic acid deficiency, or chronic disease (Black & Hawks,

2009). The low hematocrit and low hemoglobin levels are simply a result of the decreased RBC

count. The low hemoglobin is a result of the low RBCs due to the fact that hemoglobin is a


protein with in the RBCs. When the total number of circulating RBCs decrease, as in C.C.’s

case, the hemoglobin also decreases. Hematocrit percentage is also directly dependent on the

RBCs. Hematocrit is a measurement in percentage of the RBC’s concentration in blood. As the

RBC count decreases and the plasma remains constant the RBC percentage decreases which is

indicated by the low hematocrit percentage (Black and Hawks, 2009).

Medication Information

Information utilized to compile the following chart was obtained from the Davis Drug

Guide (Deglin & Vallerand, 2009) unless otherwise indicated.

Name Lisinopril 40mg/day oral

Class Antihypertensives

Action Angiotensin-converting enzyme (ACE) inhibitors block the conversion of

angiotensin I to the vasoconstrictor angiotensin II. ACE inhibitors also prevent

the degradation of bradykinin and other vasodilatory prostaglandins. ACE

inhibitors also plasma renin levels and aldosterone levels. Net result is

systemic vasodilation.

Indication • Alone or with other agents in the management of hypertension.

• Management of heart failure.

• Reduction of risk of death or development of heart failure after myocardial

infarction.

Dose Range 10 mg once daily, can be up to 20–40 mg/day

Adverse Reactions CNS: dizziness, fatigue, headache, weakness

Resp: cough.


CV: hypotension, chest pain.

GI: abdominal pain, diarrhea, nausea, vomiting.

GU: erectile dysfunction, impaired renal function.

Derm: rashes.

F and E: hyperkalemia.

Misc: angioedema.

Nursing

Considerations

Name confusion has occurred between lisinopril and fosinopril; use caution.

• Begin drug within 24 hr of acute MI; ensure that patient is also receiving

standard treatment (eg thrombolytics, aspirin, beta blockers).

• Keep epinephrine readily available in case of angioedema of the face or neck

region; if breathing difficulty occurs, consult physician, and administer

epinephrine.

• Alert surgeon, and mark patient's chart with notice that lisinopril is being

taken. The angiotensin II formation subsequent to compensatory renin release

during surgery will be blocked. Hypotension may be reversed with volume

expansion.

• Monitor patients on diuretic therapy for excessive hypotension following the

first few doses of lisinopril.

• Monitor patients closely in any situation that may lead to a decrease in BP

secondary to reduction in fluid volume (excessive perspiration and

dehydration, vomiting, diarrhea) because excessive hypotension may occur.

• Arrange for reduced dosage in patients with impaired renal function.

Medication C.C. is on this prescribed ACE inhibitor to control is hypertension. On


Interpretation morning assessment C.C.’s blood pressure was read at 144/70. The

physician’s notes in the chart indicated that C.C. had been on this medication

regiment for her blood pressure for several years. Given that the systolic

pressure was elevated currently, a change in medication may have beeen

indicated. Changes are often made to medication regiments when

hypertension still presents, as different patients react differently to different

medications. Trial and error is often used to determine the best treatment

(Black & Hawks, 2009).

Name Propranolol HCL 80mg/day oral

Class antianginals, antiarrhythmics (Class II), antihypertensives, vascular headache

suppressants

Action Blocks stimulation of beta1(myocardial) and beta2 (pulmonary, vascular, and

uterine)-adrenergic receptor sites.

Indication • Management of hypertension, angina, arrhythmias, hypertrophic

cardiomyopathy, thyrotoxicosis, essential tremors, pheochromocytoma.

• Also used in the prevention and management of MI, and the prevention of

vascular headaches.

Dose Range Antianginal — 80–320 mg/day in 2–4 divided doses or once daily as

extended/sustained-release capsules.

Antihypertensive — 40 mg twice daily initially; may be as needed (usual

range 120–240 mg/day; doses up to 1 g/day have been used); or 80 mg once

daily as extended/sustained-release capsules, as needed up to 120 mg.


InnoPran XL dosing form is designed to be given once daily at bedtime.

Antiarrhythmic — 10–30 mg 3–4 times daily.

Prevention of MI — 180–240 mg/day in divided doses.

Hypertrophic cardiomyopathy — 20–40 mg 3–4 times daily.

Adjunct therapy of pheochromocytoma — 20 mg 3 times daily to 40 mg 3–4

times daily concurrently with alpha-blocking therapy, started 3 days before

surgery is planned.

Vascular headache prevention — 20 mg 4 times daily or 80 mg/day as

extended/sustained-release capsules; may be as needed up to 240 mg/day.

Management of tremor — 40 mg twice daily; may be up to 120 mg/day (up to

320 mg have been used).

Adverse Reactions CNS: fatigue, weakness, anxiety, dizziness, drowsiness, insomnia, memory

loss, mental depression, mental status changes, nervousness, nightmares.

EENT: blurred vision, dry eyes, nasal stuffiness.

Resp: bronchospasm, wheezing.

CV: arrhythmias, bradycardia, chf, pulmonary edema, orthostatic hypotension,

peripheral vasoconstriction.

GI: constipation, diarrhea, nausea.

GU: erectile dysfunction, libido.

Derm: itching, rashes.

Endo: hyperglycemia, hypoglycemia ( in children).

MS: arthralgia, back pain, muscle cramps.

Neuro: paresthesia. Misc: drug-induced lupus syndrome.


Nursing

Considerations

• Take apical pulse prior to administering. If <50 bpm or if arrhythmia occurs,

withhold medication and notify physician or other health care professional.

• Monitor blood pressure and pulse frequently during dose adjustment period

and periodically during therapy.

• Instruct patient to take medication as directed, at the same time each day,

even if feeling well; do not skip or double up on missed doses. Take missed

doses as soon as possible up to 4 hr before next dose (8 hr with extended-

release propranolol). Inform patient that abrupt withdrawal can cause life-

threatening arrhythmias, hypertension, or myocardial ischemia.

• Advise patient to make sure enough medication is available for weekends,

holidays, and vacations. A written prescription may be kept in wallet in case of

emergency.

• Teach patient and family how to check pulse daily and blood pressure

biweekly. Advise patient to hold dose and contact health care professional if

pulse is <50 bpm or blood pressure changes significantly.

• May cause drowsiness or dizziness. Caution patients to avoid driving or

other activities that require alertness until response to the drug is known.

• Advise patients to change positions slowly to minimize orthostatic

hypotension, especially during initiation of therapy or when dose is increased.

• Caution patient that this medication may increase sensitivity to cold.

• Instruct patient to ask a health care professional before taking any OTC

medications or herbal products, especially cold preparations, when taking this

medication.


• Diabetic patients should closely monitor blood glucose, especially if

weakness, malaise, irritability, or fatigue occurs. May mask tachycardia and

increased blood pressure as signs of hypoglycemia, but dizziness and sweating

may still occur.

Medication

Interpretation

C.C. is taking this medication as an adjunct therapy to Lisinopril. This is to

aid in the control of her hypertension. The medical notes indicate propranolol

has also been part of C.C.s medication regiment for several years as well.

Name Ambien 5mg PRN PO

Class sedative/hypnotics

Action • Produces CNS depression by binding to GABA receptors.

• Has no analgesic properties.

Indication Insomnia

Dose Range • PO, SL (Adults): Tablets, spray, or SL tablets — 10 mg at bedtime;

Extended-release tablets — 12.5 mg at bedtime .

• PO, SL (Geriatric Patients , Debilitated Patients, or Patients with Hepatic

Impairment): Tablets, spray or SL tablets — 5 mg at bedtime initially;

Extended-release tablets — 6.25 mg at bedtime.

Adverse Reactions CNS: daytime drowsiness, dizziness, abnormal thinking, amnesia, behavior

changes, "drugged" feeling, hallucinations, sleep-driving.

GI: diarrhea, nausea, vomiting.

Misc: anaphylactic reactions, hypersensitivity reactions, physical dependence,

psychological dependence, tolerance.


Nursing

Considerations

• Assess mental status, sleep patterns, and potential for abuse prior to

administration. Prolonged use of >7–10 days may lead to physical and

psychological dependence. Limit amount of drug available to the patient.

• Assess alertness at time of peak effect. Notify health care professional if

desired sedation does not occur.

• Assess patient for pain. Medicate as needed. Untreated pain decreases

sedative effects.

• Because of rapid onset, advise patient to go to bed immediately after taking

zolpidem.

• May cause daytime drowsiness or dizziness. Advise patient to avoid driving

or other activities requiring alertness until response to this medication is

known.

• Caution patient that complex sleep-related behaviors (sleep-driving) may

occur while asleep.

• Advise patient to notify health care professional immediately if signs of

anaphylaxis (swelling of the tongue or throat, trouble breathing, and nausea

and vomiting) occur.

• Caution patient to avoid concurrent use of alcohol or other CNS

depressants.

Medication

Interpretation

C.C. has ambien prescribed to be taken as needed to help aid her if she has

trouble sleeping. Often the sleep pattern of older adults is disrupted while

staying in the hospital or nursing home due to unfamiliar surroundings and

constant assessments made though out the night (Tabloski, 2009).


Name Acetaminophen 650mg q6h PRN PO

Class antipyretics, nonopioid analgesics

Action • Inhibits the synthesis of prostaglandins that may serve as mediators of pain

and fever, primarily in the CNS.

• Has no significant anti-inflammatory properties or GI toxicity.

Indication • Mild pain.

• Fever.

Dose Range • PO (Adults and Children >12 yr): 325–650 mg q 4–6 hr or 1 g 3–4 times

daily or 1300 mg q 8 hr (not to exceed 4 g or 2.5 g/24 hr in patients with

hepatic/renal impairment).

Adverse Reactions GI: hepatic failure, hepatotoxicity (overdose).

GU: renal failure (high doses/chronic use).

Hemat: neutropenia, pancytopenia, leukopenia.

Derm: rash, urticaria.

Nursing

Considerations

• When combined with opioids do not exceed the maximum recommended

daily dose of acetaminophen.

• PO: Administer with a full glass of water. › May be taken with food or on

an empty stomach.

• Advise patient to take medication exactly as directed and not to take more

than the recommended amount. Chronic excessive use of > 4 g/day (2 g in

chronic alcoholics) may lead to hepatotoxicity, renal or cardiac damage.

Adults should not take acetaminophen longer than 10 days and children not


longer than 5 days unless directed by health care professional. Short-term

doses of acetaminophen with salicylates or NSAIDs should not exceed the

recommended daily dose of either drug alone.

• Advise patient to avoid alcohol (3 or more glasses per day increase the risk

of liver damage) if taking more than an occasional 1–2 doses and to avoid

taking concurrently with salicylates or NSAIDs for more than a few days,

unless directed by health care professional.

Medication

Interpretation

Acetaminophen has been ordered to help relieve any pain that C.C. may

experience as a result of current lumbar pain (Black & Hawks, 2009).

Name Oxycodone Extended Release 20mg BID, Oral

Class opioid analgesics

Action • Bind to opiate receptors in the CNS. Alter the perception of and response to

painful stimuli while producing generalized CNS depression.

Indication • Moderate to severe pain.

Dose Range Larger doses may be required during chronic therapy

• PO (Adults 50 kg): 5–10 mg q 3–4 hr initially, as needed. Controlled-

release tablets (Oxycontin) may be given q 12 hr.

• PO (Adults <50 kg or Children ): 0.2 mg/kg q 3–4 hr initially, as needed.

• Rect (Adults): 10–40 mg 3–4 times daily initially, as needed.

Adverse Reactions CNS: confusion, sedation, dizziness, dysphoria, euphoria, floating feeling,

hallucinations, headache, unusual dreams.

EENT: blurred vision, diplopia, miosis.


Resp: respiratory depression.

CV: orthostatic hypotension.

GI: constipation, dry mouth, nausea, vomiting.

GU: urinary retention.

Derm: flushing, sweating.

Misc: physical dependence, psychological dependence, tolerance.

Nursing

Considerations

• High Alert: Accidental overdose of opioid analgesics has resulted in

fatalities. Before administering, clarify all ambiguous orders; have second

practitioner independently check original order and dose calculations.

• Explain therapeutic value of medication prior to administration to enhance

the analgesic effect. › Regularly administered doses may be more effective

than PRN administration. Analgesic is more effective if given before pain

becomes severe.

› Coadministration with nonopioid analgesics may have additive analgesic

effects and may permit lower doses.

› Oxycodone should be discontinued gradually after long-term use to prevent

withdrawal symptoms.

• PO: May be administered with food or milk to minimize GI irritation. ›

Administer solution with properly calibrated measuring device.

› Controlled-release tablets should be swallowed whole; do not crush, break,

or chew.

• Controlled Release: Dose should be based on 24-hr opioid requirement

determined with short-acting opioids then converted to controlled-release form


Medication

Interpretation

Oxycodone has been ordered to help relieve any pain that C.C. may experience

as a result of current lumbar pain (Black & Hawks, 2009).

Name Miralax powder 17 g/dose ,twice a day oral

Class Laxative

Action • Polyethylene glycol (PEG) in solution acts as an osmotic agent, drawing

water into the lumen of the GI tract

Indication • Treatment of occasional constipation.

Dose Range • PO (Adults): 17 g (heaping tablespoon) in 8 oz of water; may be used for up

to 2 wk.

Adverse Reactions GI: abdominal bloating, cramping, flatulence, nausea.

Nursing

Considerations

• PO: Dissolve powder in 8 oz of water prior to administration.

Medication

Interpretation

C.C. is not drinking as much water as she should be, she is taking an opioid

analgesic, and not ambulating much. All of these factor into to her being

constipated and in need of a laxative (Black & Hawks, 2009).

Name Precose 25mg Once a Day

Class antidiabetics

Action • Lowers blood glucose by inhibiting the enzyme alpha-glucosidase in the GI

tract. Delays and reduces glucose absorption.

Indication • Management of type 2 diabetes in conjunction with dietary therapy; may be

used with insulin or other hypoglycemic agents.


Dose Range • PO (Adults): 25 mg 3 times daily; may be increased q 4–8 wk as

needed/tolerated (range 50–100 mg 3 times daily; not to exceed 50 mg 3 times

daily in patients 60 kg or 100 mg 3 times daily in patients >60 kg).

Adverse Reactions GI: abdominal pain, diarrhea, flatulence, transaminases.

Nursing

Considerations

• Patients stabilized on a diabetic regimen who are exposed to stress, fever,

trauma, infection, or surgery may require administration of insulin. › Does not

cause hypoglycemia when taken while fasting, but may increase hypoglycemic

effect of other hypoglycemic agents.

• PO: Administer with first bite of each meal 3 times/day.

Medication

Interpretation

Precose has been ordered to control and maintain C.C.’s blood glucose levels.

She has been ordered only one dose a day based on her currently stable blood

sugars and the fact that she is not eating regular meals currently.

Concept Care Map

Please refer to appendix A to view the concept care map.

Concept Care Map Analysis - Planning, Intervention, Documentation and Evaluation.

The following nursing diagnosis, and goals were obtained from LWWmobile, 2008,

unless otherwise indicated.

Nursing Diagnosis Chronic Pain related to a musculoskeletal disorder as evidenced by displaced

lumbar intervertebral disk

Goal Goal 1(short term):

The patient will have pain control though medication administration during

shift as needed.


Goal 2 (long term):

The patient will verbalize adequate relief of pain during facility stay.

Interventions 1. Intervention: Educate patient in regard to medications, dosage and side

effects.

Rational: An appropriate level of understanding in regard to medications

enables more appropriate medication choices for the patient (Black & Hawks,

2009).

2. Intervention: Evaluate the patient’s response to pain medication within

one hour of pain medication administration

Rational: monitoring the effectiveness of pain management techniques are

effective and important for assessing and maintaining pain management

(Black & Hawks, 2009).

3. Intervention: Assess the patient’s level and quality of pain every shift

Rational: pain management begins with a baseline assessment (Black &

Hawks, 2009).

4. Intervention: Assess the patient’s ability to utilize non pharmacological

techniques aimed at controlling pain during stay

Rationale: non-pharmacological techniques are used to provide pain relief in

addition to pharmacological measures (Black & Hawks, 2009).

Evaluation of Goal Goal 1: Goal met. Upon arrival the patient described pain to be at a 3/10

with ambulation. At end of shift patient described pain at a 0/10.

Goal 2: Unable to fully assess. Patient was not seen at end of stay. However,

current care shows the patient on a path to pain management.


Nursing Diagnosis Risk for constipation as evidenced by ordered opioid analgesics, and impaired

ambulation

Goal Goal 1(short term): patient report normal bowel movement every one to two

days

Goal 2(long term): Patient will remain free of fecal impaction during facility

stay

Interventions 1. Intervention: Assess bowel sound q4H

Rational: Assessment is key to determine an increase or decrease in bowel

sounds, increased bowel sounds will indicate increased parastolisis (Black &

Hawks, 2009)

2. Intervention: Encourage patient to drink 300 mL of warm water 30

minutes before meal times

Rational: Warm water consumption aids to stimulate bowel movements

(Craven & Hirnel, 2008)

3. Intervention: Encourage fluid intake to 100ml/hr

Rational: additional hydration will aid in stool softening, and increase

peristalsis (Hill, 2007).

4. Intervention: increase physical activity and ambulation as tolerated

Rationale: the increase in mobility will increase peristalsis and aid in bowel

movements (Hill, 2007).

Evaluation of Goal Goal 1: Goal met. C.C. reports that she had a bowel movement one day


prior. She also states an understanding of the need for extra hydration and

ambulation due to her medications and potential risk of constipation. C.C.

expresses the understanding of the need to adhere to interventions in order to

not need pharmaceutical interventions.

Goal 2: Goal partially met. C.C. is currently free of any signs or symptoms

of a fecal impaction. I was unable to assess her throughout her stay at

Altercare, as our clinical location changed to Mercy Medical Center for the

completion of the semester.

Nursing Diagnosis Impaired physical mobility related to musculoskeletal impairment and pain,

as evidenced by diagnosis of displaced lumbar intervertebral disk and pain

rating of 3/10 with ambulation.

Goal Goal 1(short term): patient will ambulant and transfer with independence for

remainder of shift

Goal 2(long term): Patient will report an increase in strength before

discharge

Interventions 1. Intervention: Encourage ambulation as tolerated throughout shift

Rational: increased activity will lead to increases strength and independence

(Black & Hawks, 2009)

2. Intervention: Assist with balance activities while patient is ambulating

Rational: reinforce information that has been taught to the patient by the

physical therapist will aid in the patient’s progress toward balance and


strength (Black & Hawks, 2009)

3. Intervention: Teach and encourage range of motion exercises that the

patient is able to do while in bed

Rational: the exercises will improve the patient strength and independence

while safely in bed (Black & Hawks, 2009).

4. Intervention: encourage frequent opportunities for the patient to transfer

from the bed to chair and back two times per shift

Rationale: independent transferring will increase strength as well as

independence (Black & Hawks, 2009).

Evaluation of Goal Goal 1: Goal met. C.C. ambulated to bathroom and to dining room with no

assistance. She needed to take her time and move slowly but she was able to

do everything she wanted and go everywhere she wanted independently. I

was careful to watch as she progressed down the hall just in case she became

too week to continue. However, she did very well and made it from her room

to the dining hall with her walker and no other assistance.

Goal 2: Goal partially met. C.C. is currently showing signs of increased

strength and balance. I was unable to continue to assess her throughout her

stay at Altercare, as our clinical location changed to Mercy Medical Center

for the completion of the semester.

Conclusion


At the conclusion of the shift it was my observation that C.C. had done quite well

throughout the day which I cared for her. Her physical status did not change much during the

course of my shift, except that as the night progressed she ambulated more frequently. As for

her spirits and general mood, she seemed to be feeling more comfortable and have a better

acceptance of her current condition. I was able to spend a great deal of time with her as a result

of her being one of only two patients for the day. As the day progressed she became more

comfortable with me and opened up about her ups and downs she has experienced both

physically and mentally throughout her life and current diagnosis.


References

Black, J.M., Hawks, J.H. (2009). Medical-surgical nursing: Clinical management for positive

outcomes. (8th ed). St. Louis, MO: Saunders, an imprint of Elsevier Inc. Craven, R.F.,&

Hirnel, C.J. (Ed.). (2008). Fundamentals of nursing(6th ed.). Philadelphia, PA: Wolters

Kluwer

Craven, R.F. & Hirnle, C.J. (2009). Fundamentals of nursing: Human health and function. (6th

ed). Philadelphia: Lippincott Company.

Deglin, J., H., & Vallerand, A., H. (2009). Davis’s drug guide for nurses (11th

ed). Philadelphia:

F. A. Davis Company.

Hill, R. (2007). Conquering constipation. LPN, 3(4), 48-53. Retrieved from

http://www.nursingcenter.com/pdf.asp?AID=730744

Tabloski, P.A. (2009). Gerontological nursing (2nd

ed.). Upper Saddle River, NJ: Pearson

Prentice Hall.

Documents

Running head: Displacement of Lumbar Intervertebral Disc Without Myelopathy 1mriedy.yolasite.com/resources/gero process paper.pdf · · 2011-12-05Running head: Displacement of Lumbar