NRSG 105

Nursing Care Plan Students Name____Tracy Riddle___________________________________ Dates of Care ___10/26/2013- resent ______ !ysician Dr" #ie$% &D____________ t" Dia'noses ()nclude any Sur'ical rocedures done since admission*+ Coronary ,rtery Disease% &)% Ri'!t !ifracture% dysli-idemia% ./RD% rior C,0.% .laucoma% De-ression% ressure 1lcer (left foot2 !eal*% /so-!a'eal as-iration% arteriosclerosis
Gordons Functional Health Patterns Assessment Data ( nclude normal and a!normal" # Health Histor$%Health Perce&tion S'()*C+ ,*
Health &erce&tion.

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General a&&earance+

3) feel li4e my o5erall !ealt! is 'ood ri'!t no6"7 30rea4in' my !i- 6as t!e 6orst t!in' t!at e5er !a--ened to me"7 3)n 8une of t!is year% one afternoon ) 6as at !ome $y myself and ) started cou'!in'% c!o4in' and 6as stru''lin' to catc! my $reat!"7 3) fell to t!e 'round and felt -ain in my le'"7 3) tried to 'et u- and t!e -ain 6as so $ad ) couldnt"7 3) !ad my cell -!one and called 911 and laid t!ere until t!ey came"7 3T!ey too4 me to t!e !os-ital in t!e am$ulance and ) !ad emer'ency sur'ery on my !i-"7 3) 6as in t!e !os-ital for : days"7 3,fter t!at ) came !ere $ecause ) li5e alone and ) couldnt ta4e care of myself% $ut ) am !o-in' to 'et $etter so ) can 'o !ome a'ain"7
/i0est$le.

General a&&earance. Race. Caucasian Gender. male Age grou&. elderly (od$ !uild. a5era'e Stature. slender Grooming. -t" 6as clean% clot!in' 6as clean% !air s!ort% strai'!t% fine% 'rey color"
1ental Status+ ,lert/oriented @3 Signs o0 Distress+ none -2erall health status+ t eA-erienced e5ident -ain !is ri'!t !i- 6!en assistin' -t 6it! mornin' ,D#s" ts ina$ility to am$ulate 6it! use of ri'!t le' 6as e5ident 6it! full assistance needed" t -resently is a full time% -ermanent resident% alt!ou'! !e still eA-resses t!e desire to return to !is -reBadmittance residence" ,S. + 9C"2% RR 1C$-m% (P 10>/69% -5 96D room air

;loor is one le5el at #TC facility" t" states 3) am li5in' !ere for no6 $ut !o-e to 'o !ome after ) 'et $etter"7 Health 1aintenance. Ha!its. use o0 alcohol. t" states none 'se o0 to!acco. t" states none -ther Recreational or -+C Drugs. t" states none Pre2enti2e Health (eha2iors. (reast or testicular sel03e4amination. t states 3No% ) dont"7 Date o0 last dental e4amination t states 3<!en ) 6as in my t6enties ) started !a5in' -ro$lems 6it! my teet! and ) !ad t!em all -ulled and !a5e dentures e5er since"7 Pro!lems that could contri!ute to 0alls or accidents. t re-orts -ain in !is ri'!t !i- and le'% 3) cant stand on my o6n $ecause of t!e -ain ) !a5e in my ri'!t !i-"7 Famil$ histor$ = 3&y mot!er died 6!en ) 6as >? from female com-lications and ) dont 4no6 a$out my fat!er"7
C/0: NS. 111NC

Nursing Diagnosis m&aired &h$sical mo!ilit$ r%t decrease strength and endurance secondar$ to hi& 0racture as e2idence &t# statement o0 &ain 6hen tr$ing to am!ulate on right leg Ris7 0or 0alls r%t histor$ o0 0alls De&ression r%t &resent ho&elessness o0 li2ing in /+C 0acilit$ A*( Pt# stating 6anting to go home# # N1TR)T)EN &/T,0E#)C

S'()*C+ ,*
Pre2ious Dietar$ nta7e. Diet. 3) !a5e to eat foods t!at are -ureed and soft $ecause ) !a5e -ro$lems s6allo6in' since ) !ad my !eart attac4 ) also !a5e to eat a lo6 c!olesterol diet"7 3) 6as 'oin' to a s-eec! t!era-ist% to !el- me 6it! my s6allo6in' -ro$lems% $ut ) told t!em ) didnt 6ant to 'o anymore% ) didnt feel li4e it 6as !el-in' me"7 ,itamins or su&&lements. 3/5ery mornin' t!ey 'i5e me a 5itamin $efore $rea4fast"7 Food Pre0erences. 3) 6ould rat!er eat my food solid and not -ureed $ecause sometimes t!e meat and 5e'eta$les dont loo4 as 'ood all smas!ed u- li4e t!at and some!o6 t!ey Fust dont taste t!e same eit!er"7 A&&etite 3) !a5e $een eatin' $etter in t!e last t6o mont!s and 'ettin' my a--etite $ac4"7 Nutritional m&airment. 3Since ) !ad my !eart attac4 ) !a5e -ro$lems s6allo6in'"7 8eight Fluctuations /ast 9 months. 3,fter ) !ad my fall ) lost a$out >0 l$s" $ecause ) lost my a--etite $ut in t!e last cou-le of mont!s ) !a5e $een eatin' $etter and 'ainin' $ac4 some of my 6ei'!t"7 Dentures. 3) !a5e !ad dentures since ) 6as in my middle t6enties"7 Allergies. t" NGD, Histor$ o0 S7in%Healing Pro!lems t" states none 'sual H$giene Practices. 3<e 'et to s!o6er a$out t6o to t!ree times a 6ee4"7 S7in Care Aides. Ny- statin ointment2 t" states used -rn for s4in ra6ness" +em&erature ranges. t" states cool/6arm" 9: ;-9C ;

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Height and 8eight+ 6 ft" / 133l$s" (od$ +em&erature. 9C"2 ; S: N. Color. -in4 Color ,ariations. senile lenti'ines% face% arms% le's% c!est% stomac! /esions. /5ident sur'ical scar (a--roAimately > inc!es $ilateral* su-erior midline of c!est related to C,0. sur'ery% 10/2009% -ale -in4 in color" Ri'!t le' e5ident sur'ical scar (a--roAimately 6 inc!es lon'% $ilateral*% on anterior% su-erior t!i'!% related to ri'!t !i- fracture sur'ery 06/06/2013% -ale -in4 in color" #eft le' e5ident sur'ical scar (a--roAimately ? inc!es $ilateral*% on -osterior% inferior t!i'!% related to C,0. sur'ery% 10/2009% -ale -in4 in color" +e4ture. smoot!% soft" +urgor. return immediate +em&erature and 1oisture. 6arm% dry *dema. none noted HA R. Color. 'rey /ength. s!ort% at nec4 line +e4ture. fine Distri!ution. t!in on su-erior -art of !ead% e5enly distri$uted ot!er6ise% a--ro-riate for a'e Scal&. clean% no lesions/$um-s2 some dry -atc!es to6ards fore!ead" -ral 1ucous 1em!ranes. Color. -in4 Consistenc$. smoot!% moist Gums. -in4% moist% nonedematous NA /S. Color. -in4 (ri'!t !and/ left !and* Sha&e. symmetrical to fin'er s!a-e (ri'!t !and/(left !and* +e4ture. smoot! (ri'!t !and/left !and* Nail !ed. -in4 (ri'!t !and/left !and* 3H Ca&illar$ Re0ill. 1-2 sec (ri'!t !and/left !and* Decu!itus Ris7 Factor. none noted +eeth. dentures2 u--er and lo6er full -late

C/0: NS. 111NC

Condition. fit -ro-erly u--er and lo6er -late Color+ 6!ite Dietar$ nta7e. c!arts states soft foods (-urred or softened*% lo6 c!olesterol Amount eaten. ;5< Fluid nta7e during care. -ral. 0luid inta7e o0 a&&ro4# 1000ml dail$ C!art li-id -anel la$ test recordin's 10/2013 reflect c!ronic increased le5els of ele5ated serum li-id le5els (tri'lyceride le5els 3>?m'/d#% c!olesterol 220m'/d#% #D# 1>?m'/d# all disad5anta'eous" C!art recordin' states -t" declined t!e need to continue s-eec! t!era-y -rescri$ed $y !ealt! care -ro5ider after four mont!s of t!era-y" E$ser5ation of -t" 6!ile eatin' $rea4fast 11/0?/2013 eA-ressed e5idence of -t" need to resume s-eec! t!era-y due to difficulty in s6allo6in' 6!ile eatin' and ris4 for as-iration" Nursing Diagnosis. )m-aired s6allo6in' r/t neuromuscular im-airment ,/0 need for -t" to recei5e diet of soft -ureed food $ecause of ina$ility to s6allo6 solid food due to -re5ious &) Ris4 for ad5anced de5elo-ment of decreased cardiac out-ut r/t increased 5ascular resistance Ris4 for as-iration r/t im-aired s6allo6in' )neffecti5e ,ir6ay Clearance r/t neuromuscular dysfunction ,/0 -t" states e-isode of as-iration Ris4 for )m$alanced Nutrition+ less t!an $ody reIuirements r/t 6ei'!t 20D less ideal for !ei'!t and frame Dia'nostic studies+ ,#T% ,1C% #) )D RE;)#/ # */ 1 NA+ -N

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Pre2ious 'rinar$ Pattern. 3) !a5e to !el- usin' t!e $at!room $ecause ) am una$le to stand or 6al4 $ecause of my !i- -ain"7 Fre=uenc$ o0 2oiding+ t" states !e 5oids a--roA" > @s a day Pro!lems+ t" stated none Pre2ious (o6el Pattern. 3) !a5e a $o6el mo5ement usually once a day% in t!e mornin'"7 3&y doctor orders me &iralaA if ) 'et consti-ated"7 Presence o0 hea2$ &ers&iration%dia&horesis t" states none"

-()*C+ ,*
'rinar$ C!art states2 need for full assistance at all times" 1se of s!o6er c!air" 1ode. Toilet 6it! aid of s!o6er c!air Color. #i'!t yello6 Characteristics. Clear% lo6 odor (o6el%stool (o6el Sounds. audi$le eIually in all four Iuadrants A!dominal a&&earance. Contour. round% flat S$mmetr$. symmetrical Sur0ace motion+ no mo5ement Feces. Color. li'!t $ro6n Amount. med Consistenc$. semi solid Characteristics. aromatic Drainage. None noted t" uses incontinence $riefs consistently daily"

C/0: NS. 111NC

Nursing Diagnosis. N%A Dia'nostic studies+ none ,# AC+ , +> 3 *?*RC S*

S'()*C+ ,*
Pre2ious &attern o0 acti2it$. 3) usually dont eat in my room"7 3) 'et do6n to t!e dinin' room usin' my 6!eel c!air"7 3) am not a$le to 'et dressed on my o6n or e5en 'et out of $ed% and t!at is one of t!e reasons ) !a5e to stay !ere"7 ) li5e alone and ) do not !a5e anyone to !el- me t!ere"7 ,idin' -t from c!air to $ed2 3) s-end most of my time in t!e 6!eel c!air $ecause ) cannot 'et u- on my o6n"7 3T!e -ain in my ri'!t !i- doesnt allo6 me to -ut muc! 6ei'!t on t!at side so if ) 6ant to ta4e a na- or 'o to slee- for t!e ni'!t ) !a5e to !a5e t!e nurses come and !el- me"7 3<e 'et to ta4e a s!o6er t6o to t!ree times a 6ee4"7 3T!e nurses -ut t!at rollin' c!air in t!e s!o6er for me so t!ey dont !a5e to stand 6it! me t!e 6!ole time"7 1o!ilit$ aids. t states !e uses 6!eelc!air for mo$ility and s!o6er c!air 6!en $at!in'" /imitations in a!ilit$. t states 3T!e -ain in my ri'!t !iand le' is not 'ettin' muc! $etter% it !ad $een a 5ery slo6 -rocess $ecause of t!e -ain"7 ,ital sign ranges. 3&y $lood -ressure !ad 'otten $etter since ) !a5e $een !ere"7 3)t used to $e around 1?0/90 and since ) came !ere it a lot lo6er"7 t" 0 ran'es from 10>/69 to 11:/:6 -er c!art recordin's

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Present &attern o0 acti2it$. t" self-feed/ drin4s" ,ssisted -t" 6it! dressin' and !y'iene" Need of assistance for all ,D#s" t" 6as a$le to com$ !air and -ut 'lasses on and dentures in $y !imself" Needed assistance 6it! s!a5in'" t" needed full assistance 6it! toiletin'" t" transferred from c!air to $ed 6it! !uman assistance" t reco'niJes !e cannot -erform ,D#s 6it!out assistance 6it! t!e eAce-tion of self-feed% $y utiliJin' call li'!t assistance 6!en situation reIuire any am$ulation" ,ssist (>* noted in c!art" ;ull ,ssist (>* ersonal Ky'iene noted in c!art" Turnin' around (need of full !uman assistance* noted in c!art" &o5in' on/off toilet (not steady need of full !uman assistance* and use of s!o6er c!air" 1usculos7eletal. Posture. relaAed% sli'!t 4y-!osis 1uscle tone. sli'!t resistance 1uscle strength. 1--er eAtremities (>*2 #o6er eAtremities2 ri'!t le' (1*% left le' (3* t" facial 'rimacin' 6!en testin' ri'!t le' muscle stren't!" Gait. una$le to assess% t" is una$le to am$ulate 6it!out full assistance" (alance. needs full assistance Range o0 motion. Ran'e of motion in u--er eAtremities full 6/limitations liftin' arms o5er !ead" Ran'e in motion in lo6er eAtremities is limited 6/ -ain"

C/0: NS. 111NC

>

8eight !earing. C!art states left le' 90D2 ri'!t le' 30D" t" ri'!t le' demonstrates 6ea4ness and -ain" Cardiores&irator$. /ungs. 0reat!in' smoot!% unla$ored (reath sounds. clear in all Iuadrants% eAterior/ interior Rate. 1C $reat!s -er min"@ unla$ored Rh$thm. re'ular De&th. re'ular Cough. a$sent Heart. A&ical &ulse. 6C/min Radial -ulse+ 6C/min Rh$thm. re'ular Peri&heral ,ascular. una$le to attain -eri-!eral2 -t" non-com-liant Sensation. not tender2 can identify li'!t and deetouc! all eAtremities" 1otor. Kand 'ras-s noted as eIual (>*2 ;oot mo5ement 6as eIual (3* Present tolerance 0or acti2it$. t" !as e5ident -ain/ 6ea4ness in ri'!t lo6er eAtremities2 needed assistance in all ,D#s 6it! t!e eAce-tion of self-feed" Noted in c!art t!at -t" -ro'ress in -!ysical t!era-y for increased am$ulation in ri'!t !i- and le' !as $een slo6 -ro'ressin'" t" am$ulates 6it! aid of 6!eel c!air and mo5es from c!air to $ed and use of toilet 6it! full assistance" Nursing Diagnosis. C!ronic -ain r/t !i- fracture 06/2013 ,/0 -t" self states -ain le5el on scale of 0-10 at : and often recorded in c!art 9 Ris4 for fall+ Ris4 factor+ im-aired -!ysical mo$ility in lo6er eAtremities r/t -ain due to ri'!t !i- fracture Dia'nostic studies+ ;luid and electrolyte tests2 1ric acid test% Kemo'lo$in% ,1C

,#

S/**P 3 R*S+

S'()*C+ ,*

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C/0: NS. 111NC

Slee& &atterns. 3) normally 'o to $ed around 12+00 ,& and 'et u- around 6+00 ,&"7 Routine. 3,fter $rea4fast sometimes ) ta4e a na-% until t!ey come and 'et me for my -!ysical t!era-y"7 Slee& aides used+ t" states !e ta4es Tylenol ca-sules @ 2" E% RN for -ain in !is ri'!t !i-" 3Some ni'!ts my !icauses me a lot of -ain and 4ee-s me a6a4e"7 Pro!lems. 3T!e -ain in my ri'!t !i- causes me not to $e a$le to slee- many ni'!ts"7

-!ser2e a&&earance. t" -!ysical a--earance s!o6s no si'ns of slee- de-ri5ation" -!ser2e !eha2ior. <!ile -erformin' t!e !ead to toe assessment after $rea4fast% -t" eA-ressed si'ns of eAcessi5e tiredness $y ya6nin' se5eral times% eyes 6aterin'% and arc!in' !is $ac4 to stretc!" <!en eA-ressin' ina$ility to slee- -t" o$ser5ed ru$$in' ri'!t u--er le' and ri'!t !i- area" t"s roommate eA-ressed t!at !e is often not a$le to 'et adeIuate slee- due to -t"s restlessness durin' slee- !ours" t" num$er of slee- !ours is less t!an a5era'e r/t to -t" a'e"

Nursing Diagnosis. ;ati'ue r/t slee- ,/0 -t" statin' t!at -ain in ri'!t u--er le' and !i- area 4ee-s !im a6a4e many ni'!ts Slee- de-ri5ation r/t -rolon'ed -!ysical discomfort ,/0 -t" statin' -ain in ri'!t !i- causes slee-lessness many ni'!ts Dia'nostic studies N/,

,#

C-GN + ,* 3 P*RC*P+'A/

S'()*C+ ,*
:no6ledge /e2el *ducational le2el achie2ed. t" states /n'lis! lan'ua'e is only lan'ua'e -racticed and eA-ressed" 3) 'raduated !i'! sc!ool 19>2"7 3) attended colle'e for 2 years for auto mec!anics% and soon after ) finis!ed ) 'ot a Fo$ 6or4in' at a 'ara'e fiAin' car transmissions"7 A!ilit$ to 0ollo6 2er!al%6ritten instructions. Les De2elo&mental /e2el. No co'niti5e im-airment 6itnessed or eA-ressed $y -t" nsight. 3) really enFoy 6or4in' on cars"7 3) am 5ery 'ood at fiAin' transmissions% my customers 6ere al6ays referrin' me to t!eir friends and ) could Fust a$out fiA any transmission out t!ere"7 Past Histor$+ t" states !e !as -ositi5e -erce-tion of !eat/cold" 3Could you -lease -ut t!at s6eater on me% ) 'et cold sometimes"7 t" !as -ositi5e -erce-tion to taste/smell+ 3) li4e c!ocolate mil4 to drin4 for my mid-mornin' snac4"7 3) dont 6ear any !earin' aids% ) !a5e ne5er !ad any -ro$lems !earin'"7 C/0: NS. 111NC

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1emor$ t"s lon' term memory a--ears intact2 -t" can recite and re-eat factual e5ents and dates of !is life" t"s s!ort term memory a--ears intact2 -t" can recite and re-eat 6!at food 6as ser5ed and consumed for $rea4fast t!is mornin'" S&eech. Paralanguage. t"s s-eed of s-eec! is a--ro-riate% 5oice is soft% audi$le" Articulation. t" articulation is sli'!tly im-aired due to c!art notation of -re5ious &) attac4 incidence" E$ser5ed sli'!t slur at t!e end of 6ords eA-ressed" )m-airment did not affect my com-re!ension of -t"s eA-ressions2 6as a$le to identify all eA-ressions" Se=uencing. #o'ical" t" uses correct order of eA-ression 6!en communicatin'" A&&ro&riateness o0 content. a--ro-riate Neurological. -rientation. t" is alert/ orient to -erson/-lace/time Pu&il reaction+ /RR#, Gras& Strength. Kand 'ri- (>* ;oot mo5ement+ left foot (>*% ri'!t foot (2* /e2el o0 consciousness. t" is alert and res-onsi5e to 5er$al and en5ironmental stimuli" Perce&tual A Cogniti2e.

t" states 5isual im-airment in $ot! ri'!t/left eyes% uses eye'lasses for aid in 5isual acuity at all times" 3Could you -lease !and me my 'lasses t!ere on t!e ta$leM7 t" correctly identified 5er$ally% difference $et6een li'!t and dee- touc!" 3T!at 6as li'!t/dee- etc""" Pain Assessment. t" states !e !as radiatin' -ain in !is ri'!t u--er le' and !iarea" Rates -ain intermittently :-C on scale from 0-10" Nursing Diagnosis. Ris4 for falls r/t -ain

Hallucination. a$sent Delusions+ a$sent Attention s&an+ )ntact2 <!en -erformin' !ead to toes assessment -t" 6as attenti5e to all Iuestions and reIuests" Sensor$. ,isual m&airment. -resent2 use of eye'lasses Auditor$ m&airment. no auditory aids 6ere o$ser5ed -ther sensor$ im&airments. a$sent

Dia'nostic studies+ N/,

, #

S*/F P*RC*P+ -N 3 S*/F C-NC*P+

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De2elo&mental stage o0 li0e. t" is in /ric4sons 3/'o )nte'rity 5ersus Des-air"7 t" reminisces a$out life e5ents t!at 6ere si'nificant to !is life" 3) 6or4ed in a 'ara'e as a mec!anic for >? years and my $oss 6as al6ays tellin' me !o6 'ood ) 6as at re-airin' t!ose transmissions"7 3&y late 6ife told me after 6e 'ot married t!at ) needed to understand t!at s!e 6as al6ays ri'!t and to Fust acce-t it"7 t" smilin' 6!ile statin' t!is" A!ilit$ to accom&lish age le2el tas7s. 3) am 'oin' to -!ysical t!era-y so t!at ) can 'ain my stren't! $ac4 in my le' so t!at ) can 'o $ac4 !ome"7 Ho6 do $ou see $oursel0B t" states 3) !a5e t6o dau'!ters and ) am a -roud 'randfat!er of t6o $eautiful 'randdau'!ters"7 Strengths. 3)f ) 6as -!ysically a$le% ) could fiA any transmission out t!ere"7 3) feel as far as my !ealt!% ) am -retty 'ood"7 8ea7nesses. 3) am 'oin' to my -!ysical t!era-y $ut t!e -ain in my le' doesnt seem to $e 'ettin' any $etter and it is sto--in' me from 'ainin' my stren't! $ac4 in t!at le'"7 Perce&tion to achie2e goals. 3) 6ant to 'et my stren't! $ac4 in t!is le' (-t"s !and on ri'!t le'* so ) can 'o $ac4 !ome"7 3T!at is my 'oal% ) 6ant to li5e at !ome a'ain"7 3) C/0: NS. 111NC

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Posture *$e contact. -resent2 t" ma4es a--ro-riate eye contact" Facial e4&ression (a00ect". animated2 t" ma4es a--ro-riate facial eA-ressions" Grooming. Hair groomed. yes H$giene. 'ood 1a7eu&. a$sent Sha2en. yes Dress. neat2 clot!es fit a--ro-riately% clean/dry" A00ect. uses !ands 6!en tal4in' Descri!e. smilin' 6!en reminiscin' a$out -ast life accom-lis!ments2 fro6nin' 6!en eA-ressin' -ain and ina$ility to re'ain stren't! in ri'!t le' and ina$ility to 6al4 and li5e at !is -re5ious residence" Attitude. -leasant% a'reea$le% -ositi5e2 t" eA-resses a -ositi5e attitude to6ards -ast life eA-eriences and accom-lis!ments" Kas -ositi5e outloo4 to6ards 'oal of 'ainin' stren't! $ac4 in ri'!t le' and $ein' a$le to return to !is -re5ious residence e" *4&ressed 0eelings a!out sel0. Sel03a00irmation comments. -t" eA-resses

!a5e to $e a$le to 6al4 on my o6n $efore ) can 'o !ome"7 (od$ mage 1ood. 30rea4in' t!is !i- 6as t!e 6orst t!in' t!at !as e5er !a--en to me% $ut ) am 'oin' to 'et $etter so ) can li5e at !ome"7

'ratification for !is accom-lis!ments !e ac!ie5ed durin' occu-ation as a mec!anic Sel03derogator$ comments. -resent2 t" o-enly eA-resses on'oin' uncertainties a$out !is a$ility to re'ain stren't! in !is ri'!t le' and current immo$ility t!at in!i$its !im from returnin' to !is -re5ious residence" A&&ro&riateness o0 !eha2ior+ a--ro-riate2 t"s $e!a5ior is a--ro-riate to /ric4sons sta'es of -syc!osocial de5elo-ment" t" reminisces of e5ents in !is life t!at are si'nificant to !im" t"s facial eA-ressions and $ody lan'ua'e reflect non-re'retful life c!oices" t" !as a -ositi5e outloo4 for reac!in' !is 'oals" t" con5eys a !ealt!y self-conce-t/selfesteem"

Nursing Diagnosis. Ris4 for com-romised Resilience

R-/* R*/A+ -NSH P

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3) !a5e enFoyed tal4in' to you today"7 3<!en 6ill you $e $ac4 to see me a'ainM7 3&y t6o dau'!ters and my 'randdau'!ters come to see me a$out e5ery t6o 6ee4s"7 3) loo4 for6ard to seein' t!em% es-ecially t!e 'rand4ids"7 3) 4no6 t!at ) cannot ta4e care of myself at t!is time $ecause ) cant 6al4 on my o6n% so for no6 ) !a5e to stay !ere"7 3/5eryone !ere is nice and !el-s me anytime ) need it"7 ,'e+ C> &arital Status+ <ido6er 3&y 6ife -assed a6ay 6!en s!e 6as :2"7 Eccu-ation+ 3) 6as a mec!anic for >? years"7 Nursing Diagnosis. N%A

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t" o$ser5ed interactin' 6it! ot!ers 6ell in t!e dinin' room 6!ile eatin' $rea4fast" t" o$ser5ed -leasant% smilin'% and a--reciati5e 6it! staff" <!ile -erformin' -t" assessment -t" 6as o-timistic% and -ositi5e" t"s relations!i- 6it! -resent roommate 6as o$ser5ed to $e friendly and relaAed"

?#

S*?'A/ +> 3 R*PR-D'C+ ,*

S'()*C+ ,*
C/0: NS. 111NC

-()*C+ ,*

3&y 6ife and ) !ad t6o dau'!ters% t!ey are ??and ?: years old"7 3&y 6ife -assed a6ay 12 years a'o"7 Present se4ual acti2it$+ did not assess 'se o0 !irth control+ did not assess Prostate e4am. did not assess

(reasts. flat% -in4 Areola+ -in4 to li'!t $ro6n% round% e5en% no disc!ar'e -resent% scarce distri$uted !air Genitalia+ -resence of -u$ic !air% scarce distri$ution No 5isi$le lesions No odor No draina'e )na--ro-riate SeAual 0e!a5ior+ N/,

Nursing Diagnosis. N%A Dia'nostic studies+ N/,

?#

C-P NG 3 S+R*SS +-/*RANC*

S'()*C+ ,*
3) meet 6it! a counselor a$out e5ery t6o 6ee4s to tal4 a$out !o6 ) am feelin'"7 3) 'et de-ressed sometimes a$out !o6 lon' it is 'oin' to ta4e me to 'et my stren't! $ac4 in my le'"7 3)t is ta4in' lon'er t!an ) t!ou'!t to start 6al4in' a'ain on my o6n"7 3&y dau'!ters 'ot me a cell -!one and ) call t!em 6!en ) feel t!e need to tal4 to someone"7

-()*C+ ,*
(eha2ior &atterns+ A!use to sel0 or others+ a$sent Pt# !eha2ior is controlled /relaAed2 a--ro-riate A&&earance+ a--ro-riate 6it! eA-ressions" t" a--ears to ma4e sound decisions" &eets 6it! counselor e5ery t6o 6ee4s to address !is de-ression r/t to ina$ility to am$ulate effecti5ely in time frame eA-ected" t" -ro'ress to $i-6ee4ly counselin' re'ardin' de-ression recorded in c!art states -t" is anAious to return to !is -re5ious residence% and 6ants t!is su$Fect to $e addressed at eac! meetin'"

Nursing Diagnosis. N%A ?# ,A/'*S 3 (*/ *FS

C/0: NS. 111NC

S'()*C+ ,*
3Concern 6ith meaning o0 li0e%death. a$sent2 t" did not eA-ress any concern 6it! meanin' of life/deat!" Concern 6ith meaning o0 su00ering. a$sent2 t" did not eA-ress any concern 6it! sufferin'" Anger to6ards God%religion. a$sent2 3) am a mem$er of t!e% 3;irst 0a-tist C!urc!"7 3<!en ) first came !ere% t!e -reac!er and 1: mem$ers of t!e c!urc! came to see me at t!e same time"7 3T!e reac!er from t!e c!urc! comes !ere one a mont! to -ray 6it! me and 'i5es me communion"7

-()*C+ ,*
S$m!ols o0 Faith. -resent2 0i$le and c!urc! ne6sletter 6ere o$ser5ed on -t" side ta$le in room" t" s!o6s no unusual facial eA-ressions or a$normal $ody lan'ua'e 6!en ta4in' a$out reli'ion" No $e!a5ioral -atterns of des-air o$ser5ed"

Nursing Diagnosis. N%A

D SCHARG* N**DS #ist treatments+ N/,__ S-ecial care or needs+ N/,___ S-ecial teac!in'+ N,__ ;ollo6 u- care or a--ointments+ N/,___ #ife eA-ectancy+ Sur-assed a'e :C Reha!ilitation s&eci0$ t$&e+ N/, Return to+ #on' term care is final for -t" !ome at -resent time"

C/0: NS. 111NC

10

1*D3S'RG +*?+(--: P C+'R*

Patho&h$siolog$. 3 C-R-NAR> AR+*R> D S*AS*. Coronary artery disease (C,D* is c!aracteriJed $y at!erosclerosis in t!e e-icardial coronary arteries" ,t!erosclerotic -laIues% t!e trademar4 of at!erosclerosis% 'radually narro6 t!e coronary artery lumen and 6ea4en ante'rade myocardial $lood flo6" T!e decrease in coronary artery flo6 may $e sym-tomatic or asym-tomatic% ta4e -lace 6it! eAertion or at rest% and conclude in a myocardial infarction% de-endent on o$struction se5erity and t!e s-eed of de5elo-ment" T!e most commonly acce-ted -!iloso-!y of at!erosclerosis states t!at t!e de5elo-ment re-resents t!e $odyNs effort to !eal in res-onse to an endot!elial dama'e" T!e 1ST ste- in at!erosclerotic -ro'ression is t!e 'ro6t! of fatty strea4s% 6!ic! include at!ero'enic li-o-roteins and macro-!a'e foam cells" T!ese strea4s form in t!e middle of t!e endot!elium and internal elastic lamina" ,s time -asses a transitional lesion com-osed of an eAtracellular li-id core and layers of smoot! muscle and connecti5e tissue matriA ultimately forms a fi$rous ca-" T!e ed'e of t!e fi$rous ca- -lays a critical -art in t!e -ro'ress of acute coronary syndromes" laIue ru-ture unco5ers t!e underlyin' t!rom$o'enic core of li-id and necrotic material to flo6in' $lood and its t!rom$o'enic -articulates" T!is disclosure results in -latelet a''re'ation% ad!erence% and ad5anced luminal reduction% 6!ic! can ra-idly e5ol5e and is associated 6it! acute coronary syndromes li4e &)"
SIGNS AND SYMPTOMS Some patients who suffer symptoms due to CAD experience pain, burning, or pressure in the chest that originates or get worse with physical exertion, emotion, contact with cold air, or eating a large fatty meal. The pain is sometimes described as a smothering feeling or a shortness of breath. It is frequently located below the sternum and can emit to the upper chest, neck, jaw, shoulders, back, or arms. It can cause bloating, vomiting, nausea, or perspiration. However, patients may not be aware of the symptoms of coronary artery disease, a condition called silent ischemia, or they may blame their symptoms to another cause like heartburn or indigestion. DIAGNOSTIC STUDIES: Blood tests are drawn to distinguish if hyperlipidemia, hyperglycemia, or renal insufficiency is existing. X-rays are used to identify extreme arterial calcification. An ultrasonic evaluation of the artery is used if the pt. has symptoms that limit functionality. Arteriography is used to see if the vessels are blocked severely.
C/0: NS. 111NC

11

1*D CA/3S'RG CA/ +R*A+1*N+

, -t" t!at is dia'nosed 6it! C,D ty-ically is -rescri$ed medications to re'ulate t!eir 0 and !i'! serum li-id le5els" )n addition t!ey are 'i5en as-irin or r!eolo'ical a'ents to increase 0; t!rou'! $loc4ed arteries" Sur'ical -rocedures may $e im-lemented to o-en $loc4ed arteries and may include -rocedures of an'io-lasty% at!erectomy% or arterial $y-ass" Nursing Care ( nclude +eaching" /A-ress t!e im-ortance im-lementin' a diet t!at is lo6 in salt% fat% and c!olesterol"
Teac! t" to eAercise to increase $lood flo6"%

0e alert to ad5erse reaction related to a$ru-t discontinuation of $eta-adrener'ic $loc4er and calcium c!annel $loc4er t!era-y" T!ese dru' must $e ta-ered to -re5ent a 3re$ound -!enomenon72 tac!ycardia% increase in c!est -ain% and !y-ertension"
Teac! t" t!e im-ortance of ta4in' -rescri$ed medication as ad5ised"

/A-lain to t!e -atient t!e im-ortance of anAiety reduction to assist to control an'ina" Teac! t!e -atient relaAation tec!niIues" Re5ie6 6it! -t" s-ecific factors t!at affect C,D de5elo-ment and -ro'ression2 !i'!li'!t t!ose ris4 factors t!at can $e modified and controlled to reduce t!e ris4"

C/0: NS. 111NC

12

1*D3S'RG +*?+(--: P C+'R*

Patho&h$siolog$. H>P*R+*NS -N3,dult KTN a disorder in 6!ic! 0 readin's are 'reater t!an 1>0 mm K' systolic or 90 mm K' diastolic on 3 isolated readin's documented numerous 6ee4s a-art" KTN is one of t!e maFor t!reats for 4idney failure% coronary artery disease% retino-at!y% -eri-!eral 5ascular disease% !eart failure% and stro4e" )t !as an effect on a$out ?0 million -eo-le in t!e 1"S" Si'nificant in5esti'ation !as s!o6n t!at re'ulatin' KTN escalates -rolon'ed eAistence and !el-s a5oid cardio5ascular illnesses" S GNS AND S>1P+-1S. KTN is often an asym-tomatic disease in t!e first fe6 decades of its de5elo-ment and is referred to as t!e 3silent 4iller"7 T!e maFority of -atients usually s!o6 no sym-toms until -ro$lems arise% $ut t!e seriousness of KTN s!ould $e addressed" Eften -t 6!o suffer from KTN 6ill com-lain of K/," <!en com-lications result from increased 0 % -atients reference sym-toms related to certain affected or'ans" KTN is increasin'ly e5ident as -eo-le a'e" KTN (Sta'e 2* is a readin' from 160/100 - 1:9/109 mm K'" KTN (Sta'e 3* ori'inates at 1C0/110 mm K' and does not !a5e an u--er limit" ,t eac! sta'e of KTN% from -re-!y-ertensi5e le5els t!rou'! t!e 3 sta'es of KTN% t!e t!reat for stro4es% !eart attac4s% and 4idney failure% escalates"

D AGN-S+ C S+'D *S. C!olesterol -rofile% includin' tri'lyceridesysis% fastin' 'lucose le5el% serum -otassium% calcium le5els% $lood urea nitro'en% and an /C. 1*D CA/ S'RG CA/ +R*A+1*N+. ,dFustments in lifestyle to lo6er 0 6ould include c!an'es -t diet" , diet lo6 in sodium (2'rams/daily* can $e accom-lis!ed $y not addin' salt to food% a5oidin' -rocessed foods% eAcludin' salty foods2 !am% -otato c!i-s% etcO)n addition to diet% retainin' a 0&) of less t!an 2>"9 can aid in 4ee-in' 0 le5els 6it!in normal limits as 6ell as% restrictin' total inta4e of saturated fat and c!olesterol" ,lco!ol s!ould $e limited to one drin4 a day% and smo4in' s!ould $e discontinued" Eften times alon' 6it! lifestyle c!an'es% dru' t!era-y is also included for treatment of KTN" KTN (sta'e )* consists of lo6 dose t!iaJide diuretics% an'iotensin con5ertin' enJyme (,C/* in!i$itors% $eta $loc4ers% calcium c!annel $loc4ers" &edications can $e used indi5idually or can $e com$ined% de-endin' on indi5idual circumstances" )n t!e case of KTN (sta'e ))*% usually t6o-medications are -rescri$ed to'et!er a t!iaJide-ty-e diuretic alon' 6it! a ty-e of $eta $loc4er"

C/0: NS. 111NC

13

N'RS NG CAR* ( NC/'D* +*ACH NG". 0 needs to $e measured at e5ery !ealt! care 5isit" t" s!ould $e educated on t!e meanin' of 0 readin' results" Constructi5e lifestyle alterations s!ould $e encoura'ed" &edical re'imens need to $e em-!asiJed% and -atients need to $e instructed to notify t!eir KC of any increased/decreased altercations or ne'ati5e S/S of t!era-y t!ey may $e eA-eriencin' as t!ese can freIuently $e mana'ed 6it! dosa'e modification or an adFustment in medication" &onitorin' 0 at !ome can $e tau'!t to -t"s t!at are rece-ti5e" 0 readin's s!ould $e measured and documented for $ot! ri'!t and left arms" )f t!ere is a medical -ro$lem sto--in' measurement of eit!er arm% -t" s!ould s-ecify 6!ic! arm 0 6as measured on"

C/0: NS. 111NC

1>

1*D3S'RG +*?+(--: P C+'R* Patho&h$siolog$. FRAC+'R* -F +H* PR-? 1A/ F*1'R. , discontinuity or disru-tion in t!e continuity of a $one t!at commonly affects mo$ility and sensation" T!e 3sim-le7 (closed* fracture does not eAtend t!rou'! t!e s4in so t!ere is no 5isi$le 6ound on t!e outside surface of t!e le'" Ki- fractures are measured as% any -art of t!e u--er t!ird of t!e femur and are classed as intraca-sular (inside t!e Foint ca-sule* or eAtraca-sular (on t!e outside of t!e Foint ca-sule" T!ese 4inds of fractures !a5e a !i'! mortality rate as a result of multi-le difficulties related to sur'ery% sustained immo$ility% and de-ression amon' t!e elderly"

S GNS AND S>1P+-1S. Si'ns include loss mo5ement% -ain 6it! acute -ainfulness and -ossi$le immflamation o5er t!e site of fracture% and -ossi$le immediate onset of $ruisin'% deformity and -otential s!ortenin'% irre'ular mo$ility% and cre-itus or 'ratin' o5er!eard 6!en t!e ends of t!e $one ru$ to'et!er"

D AGN-S+ C S+'D *S. )mmediate first aid consists of s-lintin' of t!e fracture site and Foints directly a$o5e and $elo6 it to reduce furt!er mo5ement and dislocation" ,--lyin' a cold -ac4 to t!e fracture site and ele5atin' it a$o5e t!e !eart may reduce -ain and inflammation" Radio'ra-!y is used to classify t!e fracture and t!e eAact location of t!e $one fra'ments"
1*D CA/3S'RG CA/ +R*A+1*N+.

, -!ysician decreases t!e fracture" T!e $one is 4e-t in -osition $y a cast or s-lint until union !as set" T!e lim$ is t!en restored to full function 6it! t!e aid of -!ysical t!era-y and eAercise" )n o-en or com-ound fractures% $leedin' must $e -re5ented $efore t!e fracture is considered" T!e o-en fracture needs to $e co5ered 6it! sterile dressin' and t!e fracture site restrained" E-en reduction could -ossi$ly $e necessary" T!e 6ound is cleaned 6it! sterile saline" ,fter t!e 6ound is clean% a sterile dressin' is a--lied $y a $anda'e" T!e $one t!en can $e restrained $y eAternal fiAation in antici-ation of t!e 6ound !ealin'" )f t!e $one doesnt !eal% a 6ea4 electric current may need to $e a--lied to t!e $one ends% t!is -romotes !ealin'" Ki- fractures reIuire moderate !andlin' and restriction to a5oid dis-lacement of t!e fracture or interru-tion of a -el5ic !ematoma"

C/0: NS. 111NC

1?

N'RS NG CAR*.

,ssess -t" -ain le5el daily to determine com-lications due to -ost sur'ery !ealin'% usin' -ain scale to rate -ain of 0-10" ,dminister -rescri$ed -ain medication to mana'e -ain" 0one !ealin' and re$uildin' stren't! rely on adeIuate nutrition% t!erefore it is im-erati5e to ma4e sure -t" recei5es -ro-er nutrition es-ecially -!os-!orus% 5itamin D% calcium% and -rotein" ,ssess -t" for lo6er eAtremity edema2 t!is is t!e most common site for -ro$lems in -t" 6!o eA-erience musculos4eletal trauma" Reinforce teac!in' -ro5ided $y -!ysical t!era-ist to increase re!a$ilitation -rocess" ,ssess -t" a$ility to safely use 6!eelc!air" ,ssess -t" for -syc!olo'ical manifestations of de-ression% or stressors related to inFury and delayed eA-ectations of re!a$ilitation" ,ssist -t" 6it! daily ,D#s" &a4e sure t!at call li'!t is 6it!in reac! for -t" to call for assistance 6!en needed"

C/0: NS. 111NC

16

C/ N CA/ C-'RS* 11/01/2013% 1000+ C> y"o" 6!ite male% 6ei'!t 60 4' (133 l$"*% !ei'!t 1C3 cm(6*" lon' term care resident" ,dmitted 06/13/2013 for ina$ility to am$ulate self safely and -erform ,D#s due to fracture of t!e -roAimal femur" PS+ T+ 99"2Q; tym-anic% 0 10>/69 electronic/ri'!t arm% sittin'% R 6C/min% radial -ulse 6?/min left 6rist% sittin'% E 96 D% ,,EA3" t" KTN a--ears to $e under control 6it! administration of -rescri$ed medications 6it! recorded readin's in c!art for t!e last mont! $et6een 11C/:9 = 10>/69" t"s c!olesterol le5el remains ele5ated des-ite administration of -rescri$ed medications% last c!art recorded le5el 0C/01/2013 c!olesterol ele5ated at 220 m'/d#% tri'lyceride ele5ated at 3>? m'/d#% #D# le5el ele5ated at 1>? m'/d# and CKE#/KD# ratio ele5ated at 10"2D (not 6it!in ran'e*" t" !as a !istory of &) related to !i'! 'rade stenosis of t!e coronary arteries due to -ersistent ele5ated c!olesterol le5els and KTN" t" under6ent C,0. sur'ery 10/2009 -roceedin' &) e-isode" ,s a result of &) e-isode -t" !as difficulty s6allo6in'2 -t" !as a restricted diet of soft foods (-ureed* alon' 6it! lo6 salt and lo6 c!olesterol" t" states !e suffers from acute -ain in ri'!t !i- and u--er le' from -re5ious fracture of t!e -roAimal femur 06/06/20132 rates -ain on -ain scale of 0-10 at a 9 on 11/01/20132 c!art reflects -ain scale used daily to assess -t" -ain le5el and is recorded usin' same -ain scale in last t6o 6ee4s $et6een : and 9" t" attends -!ysical t!era-y 2 @s 6ee4ly for re!a$ilitation to stren't!en ri'!t !i- and u--er le'" t" needs com-lete assistance in all ,S#s" t" uses 6!eelc!air to am$ulate" ro'ress from t!era-y noted in c!art states -t"s -ro'ress !as $een in!i$ited $ecause of on'oin' -ain restrictin' !is a$ility to $ear 6ei'!t on ri'!t le'" t" is 'i5en -ain medication RN -er -t" reIuest" t" is dia'nosed 6it! 'laucoma in $ot! left and ri'!t eyes2 medicated -rescri-tion 'laucoma eye dro-s administered daily to $ot! eyes (DorJolamide% 0"0?D% one dro- 2@s daily*" t" eA-resses desire to 'ain stren't! in ri'!t !i- and u--er le' so t!at !e can return to !is -rior residence" t" attends -syc!olo'ical screenin's once e5ery t6o 6ee4s to assess on'oin' de-ression r/t -t" delay in re!a$ilitation allo6in' !im to return to !is -re5ious residence" t" c!art reflects de-ression and sli'!t a'itation durin' sessions" t" de5elo-ed a $lister -ressure ulcer 10/1?/2013 located on left !eal% sta'e (1* noted in c!art2 t!era-y im-lemented includes daily assessment of area 6it! dressin' c!an'es daily (Aerofom 'auJe* and air $oot a--lied to left foot 6!ile in $ed" t" self feeds" t" is on room air and does not reIuire oAy'en t!era-y" 11/12/2013 0C00% initiated communication 6it! -t" concernin' non-com-liance to attendin' s-eec! t!era-y sessions t!at aid in im-ro5in' !is a$ility to s6allo6 -roducti5ely" /ncoura'ed -t" to eA-ress !is concerns and reasons to discontinue attendin' s-eec! t!era-y" t" eA-ressed disa--ointment r/t im-ro5ed -ro'ress o$ser5ed" t" eA-ressed conflict 6it! t!era-y sc!edulin' times and days t!at -t" felt interfered 6it! -ersonal needs of relaAation and rest and often caused -t" to feel o5er6!elmed"
C/0: NS. 111NC

1:

11/12/2013 1100% educated -t" on t!e im-ortance of attendin' s-eec! t!era-y to aid in im-ro5in' s6allo6in' and -re5entin' as-irations" /ducated -t" on dan'ers r/t as-irations" 11/12/2013 1?00% su''ested -t" -ro-ose modifications concernin' t!era-y times% days and lac4 of eA-ected im-ro5ement in order to come to a resolution for !im to resume t!era-y in addition to meetin' !is -ersonal needs for rest resol5in' feelin's of $ein' o5er6!elmed" 11/1:/2013 educated -t" on non--!armacolo'ical -ain relief tec!niIues and 6!eelc!air eAercises" /A-lained diet to -romote $one and muscle 'ro6t!" .a5e -t" nutritional dietician contact information" t" recited learnin' and contacted dietician" /ducated -t" on -ain assessment and -ro-er 6ays to re-ort" t" recited leanin' and understandin' -ro-erly" 11/20/2013 educated -t" on -ro-er use of 6!eel c!air and safety -recautions% fall -re5ention safety measures and need for -t" to call for assistance 6!en am$ulatin'" t" recited learnin' and understandin' -ro-erly"

D AGN-S+ C S+'D *S

/a! studies and 43ra$s ordered. ,u'ust/01/2013+ Hemoglobin AIC 8uly 2013+ #i-id rofile+ T/ST C!olesterol Tri'lyceride KE# #D#
C/0: NS. 111NC

Result+ ?"9D Result+ 22 )1/m#

Normal Ran'es Normal Ran'es

?":D6">D 10-30 )1/m#

ALT (SGPT)

R/S1#T

NER&,# R,N./S S200 m'/d# 0-1?0 m'/d# >0-60 m'/d# 63-130 m'/d#

R 220 m'/d#
R 3>? m'/d# T 3? m'/d# R 1>? m'/d#
1C

Non-KD#/CKE CKE#/KD# R,T)E

1?> m'/d# 10"2D (NET <)TK)N R,N./*

Patient results (choose at least t6o o0 the a!o2e" Name o0 test. ,#T (S. T* Normal 2alues. 10-30 )1/m# Patient 2alues. 22 )1/m# (<N#* Signi0icance (&ur&ose o0 test@ nursing &re&aration@ e4&lain a!normal 2alues as the$ relate to the &atient". Pur&ose. To screen for li5er dama'e and/or to !el- dia'nose li5er disease"

A!normal ,alues. ,s a -erson a'es t!e incident of li5er disease and/or li5er dama'e increases" t" ta4in' -rescri-tion medications to control !i'! c!olesterol are at increased ris4 for li5er dama'e" &onitorin' li5er function must $e im-lemented to assess for li5er dama'e" Nursing Pre&aration. 1* 2* 3* >* ?* /A-lain -rocedure to -t" /A-lain t!at t!is is not a fastin' test2 no restrictions Collect a 5enous $lood sam-le/'ray to- or la5ender to- tu$e ,--ly -ressure/-ressure dressin' to 5eni-uncture site ,ssess t!e 5eni-uncture site for $leedin'

Name o0 test. Tri'lyceride Normal 2alues. 0-1?0 m'/d# Patient 2alues. R 3>? m'/d#
C/0: NS. 111NC

19

Signi0icance (&ur&ose o0 test@ nursing &re&aration@ e4&lain a!normal 2alues as the$ relate to the &atient". Pur&ose. T.s identify ris4 of de5elo-in' CKD" Test is -art of a li-id -rofile and includes measurement of CKE and li-o-roteins" A!normal ,alues. ,s a -erson a'es li-id $rea4do6n in t!e $ody decreases% t!erefore t!ey are at ris4 for !i'!er c!olesterol le5els 6!ic! can lead to stenosis of t!e coronary arteries and encoura'e transient isc!emia" T!is can lead to stimulation of 5entricular arr!yt!mias and -ro'ress into 5entricular fi$rillation leadin' to deat!" )nta4e of fatty foods can increase le5els of T.s" eo-le 6!o lead a sedentary lifestyle can !a5e increase in T. le5els" Nursing Pre&aration. 1* /A-lain -rocedure to -atient" 2* )nstruct -atient t!is is a fastin' test and t!ey !a5e to remain N E for 12-1> !ours $efore test" Enly 6ater is allo6ed 3* /A-lain no alco!ol is allo6ed for 2> !ours $efore test" >* )nform -atient t!at dietary indiscretion for as muc! as t6o 6ee4s $efore test 6ill influence test" ?* Collect a 5enous $lood sam-le in a red-to- tu$e 6* ,--ly -ressure or a -ressure dressin' to t!e 5eni-uncture site :* ,ssess t!e 5eni-uncture site for $leedin' C* &ar4 -atients a'e and 'ender on t!e la$ sli9* )nstruct -atients 6it! increased T. le5els re'ardin' diet% eAercise% and a--ro-riate 6ei'!t

C/0: NS. 111NC

20

1*D CA+ -NS

1edication Generic C (rand Name Trade Name(s* #i-itor Dose Range Client Classi0ication Dose C0 m' ta$ E 1@ d !arm" Class" !m' coa reductase in!i$itors T!er" Class" li-id-lo6erin' a'ents ndication and Action Side *00ects%Drug interactions CNS+ amnesia% confusion% diJJiness% !eadac!e% insomnia% memory loss% 6ea4ness //NT+ r!initis Res-+ $ronc!itis CP+ c!est -ain% -eri-!eral edema .)+ a$dominal cram-s% consti-ation% diarr!ea% flatus% !eart$urn% altered taste% dru'induced !e-atitis% dys-e-sia% R li5er enJymes% nausea% -ancreatitis /ndo+ !y-er'lycemia .1+ erectile dysfunction Derm+ ras!es% -ruritus &S+ RK,0DE&LE#LS)S% art!ral'ia% art!ritis% myal'ia% myositis &isc+ KL /RS/NS)T)P)TL R/,CT)ENS )NC#1D)N. ,N.)EN/1RET)C /D/&, Nursing Considerations and Contraindications -!tain a diet histor$@ es&eciall$ 6ith regard to 0at consum&tion# /a! +est Considerations. *2aluate serum cholesterol and trigl$ceride le2els !e0ore initiating@ a0ter 5AD 67 o0 thera&$@ and &eriodicall$ therea0ter# 1onitor li2er 0unction tests &rior to initiation o0 thera&$ and as clinicall$ indicated# 0 s$m&toms o0 serious li2er inEur$@ h$&er!iliru!inemia@ or Eaundice occurs discontinue ator2astatin and do not restart# 1a$ also cause F al7aline &hos&hatase and !iliru!in le2els# 0 &atient de2elo&s muscle tenderness during thera&$@ CP: le2els should !e monitored# 0 CP: le2els are G10

E+ (,dults* 10=20 m' once daily initially2 (may start 6it! >0 m'/day if #D#-C 0rand Name needs to $e T $y ,tora5astatin U>?D*2 may $e R e5ery 2=> 64 u- to C0 m'/day2 Concurrent nelfina5ir t!era-y= Dose s!ould not eAceed >0 m'/day2 Concurrent clarit!romycin% itraconaJole% saIuina5ir/ritona5ir% daruna5ir/ritona5ir% fosam-rena5ir% or fosam-rena5ir/ritona5i r t!era-y=Dose s!ould not eAceed 20 m'/day"

ndications.,dFuncti5e mana'ement of -rimary !y-erc!olesterolemia and miAed dysli-idemia" rimary -re5ention of coronary !eart disease (myocardial infarction% stro4e% an'ina% and coronary re5asculariJation* in asym-tomatic -atients 6it! increased total and lo6-density li-o-rotein (#D#* c!olesterol and decreased !i'!-density li-o-rotein (KD#* c!olesterol"

De'lin% C/0: NS. 111NC

8" K"% Pallerand% ," K"% V Sanos4i% C" ," (2010*" Davis's21 drug guide for nurses" (12t! ed"*" !iladel-!ia+ ; , Da5is Co"

Actions.)n!i$its 3!ydroAy-3met!yl'lutarylcoenJyme , (K&.Co,* reductase% an enJyme 6!ic! is res-onsi$le for catalyJin' an early stein t!e synt!esis of c!olesterol" T!era-eutic /ffect(s*+ #o6erin' of total and #D# c!olesterol and tri'lycerides" Sli'!tly increases KD# c!olesterol" Reduction of li-ids/c!olesterol reduces t!e ris4 of myocardial infarction and stro4e seIuelae" Slo6s t!e -ro'ression of coronary at!erosclerosis 6it! resultant decrease i coronary !eart disease= related e5ents"

times the u&&er limit o0 normal or m$o&ath$ occurs@ thera&$ should !e discontinued#

De'lin% 8" K"% Pallerand% ," K"% V Sanos4i% C" ," (2010*" Davis's drug guide for nurses" (12t! ed"*" !iladel-!ia+ ; , Da5is Co"

C/0: NS. 111NC

22

1edication n0ormation Form 1edication Dose Range Generic C (rand Name PO: (Adults) (meto-rolol*
Lopressor

Client Dose 2?m' E W ta$" (12"?m'* 2@s daily

Classi0ication +her# Class+ antian'inals anti!y-ertensi5es Pharm# Class. $eta $loc4ers

ndication and Action

Side *00ects%Drug interactions

Side Effects: CNS: fatigue# weakness# an!iety# depression# di88iness# dro,siness# insomnia# memory loss# mental status &*anges# nervousness# nig*tmares EENT: blurred vision# stu""y nose Resp: bron&*ospasm# ,*ee8ing CV: 6907:3097'0# /;# 1<L2=>09: %7%20# *ypotension# perip*eral vaso&onstri&tion GI: &onstipation# diarr*ea# drugindu&ed *epatitis# dry mout*# "latulen&e# gastri& pain# *eartburn# liver en8ymes# nausea# vomiting GU: erectile dysfunction# libido# urinary "requen&y De !: ras*es Endo: *ypergly&emia# *ypogly&emia "S: art*ralgia# ba&- pain# ?oint pain

Antihypertensive/antianginal 25100 mg/day as a single dose initially or 2 divided doses; may be q 7 days as needed up to 450 mg/day (immediate-release or 400 mg/day (e!tended-release ("or angina# give in divided doses $ %!tended-release produ&ts are given on&e daily$ MI2550 mg (starting 15 min a"ter last '( dose q ) *r "or 4+ *r# t*en 100 mg t,i&e daily$ Heart failure 12$525 mg on&e daily (o" e!tended-release # &an be doubled every 2 ,- up to 200 mg/day$ Migraine prevention50100 mg 24 times daily (unlabeled $ IV: (Adults) MI5 mg q 2 min "or . doses# "ollo,ed by oral dosing$

Indications:

/ypertension$ 0ngina pe&toris$

1revention o" 2' and de&reased mortality in patients ,it* re&ent 2'$ 2anagement o" stable# symptomati& (&lass '' or ''' *eart "ailure due to is&*emi&# *ypertensive or &ardiomyopat*& origin (may be used ,it* 03% in*ibitors# diureti&s and/or digo!in; 4oprol 5L only $ Actions: 6lo&-s stimulation o" beta1(myo&ardial -adrenergi& re&eptors$ 7oes not usually a""e&t beta2(pulmonary# vas&ular# uterine -adrenergi& re&eptor sites$

Nursing Considerations and Contraindications Nursing Considerations+ &onitor 0 % /C.% and -ulse freIuently durin' dose adFustment and -eriodically durin' t!era-y" X&onitor freIuency of -rescri-tion refills to determine com-liance" X &onitor 5ital si'ns and /C. e5ery ?=1? min durin' and for se5eral !ours after -arenteral administration" )f !eart rate S>0 $-m% es-ecially if cardiac out-ut is also decreased% administer atro-ine 0"2?=0"? m' )P" X &onitor inta4e and out-ut ratios and daily 6ei'!ts" ,ssess routinely for si'ns and sym-toms of K; (dys-nea% rales/crac4les% 6ei'!t 'ain% -eri-!eral edema% Fu'ular 5enous distention*" ,n'ina+ X,ssess freIuency

C/0: NS. 111NC

De'lin% 8" K"% Pallerand% ," K"% V Sanos4i% C" ," (2010*" Davis's drug guide for nurses" (12t! ed"*" !iladel-!ia+ ; , Da5is Co"

23

and c!aracteristics of an'inal attac4s -eriodically durin' t!era-y"

(References* De'lin% 8" K"% Pallerand% ," K"% V Sanos4i% C" ," (2010*" Davis's drug guide for nurses" (12t! ed"*" !iladel-!ia+ ; , Da5is Co"

Drug3Drug. X.eneral anest!esia% )P -!enytoin% and 5era-amil may cause R myocardial

Contraindications. H1ncom-ensated K;2 X ulmonary edema2 XCardio'enic s!oc42 X0radycardia% !eart $loc4% or sic4 sinus

C/0: NS. 111NC

2>

de-ression" syndrome (in XConcurrent use a$sence of a 6it! -acema4er*" am-!etamines% cocaine% e-!edrine% e-ine-!rine% nore-ine-!rine% -!enyle-!rine% or -seudoe-!edrine may result in uno--osed al-!aadrener'ic stimulation (eAcessi5e !y-ertension% $radycardia*" XConcurrent administration of t!yroid administration may T effecti5eness" X&ay alter t!e effecti5eness of insulins or oral !y-o'lycemic a'ents (dose adFustments may $e necessary*" X1se cautiously 6it!in 1> days of &,E in!i$itor
De'lin% 8" K"% Pallerand% ," K"% V Sanos4i% C" ," (2010*" Davis's drug guide for nurses" (12t! ed"*" !iladel-!ia+ ; , Da5is Co"

C/0: NS. 111NC

2?

1edication Generic C (rand Name (ome&raIole" Pri/osec

Dose Range
PO: (Adults) GERD/erosive esophagitis20 mg on&e daily$ Duodenal ulcers associated with H pylori40 mg on&e daily in t*e morning ,it* &larit*romy&in "or 2 ,-# t*en 20 mg on&e daily "or 2 ,- or 20 mg t,i&e daily ,it* &larit*romy&in 500 mg t,i&e daily and amo!i&illin 1000 mg t,i&e daily "or 10 days (i" ul&er is present at beginning o" t*erapy# &ontinue omepra8ole 20 mg daily "or 1+ more days ; *as also been used ,it* &larit*romy&in and metronida8ole$ Gastric ulcer40 mg on&e daily "or 4) ,-$ Reduction of the risk of GI !leeding in critically ill patients 40 mg initially# t*en anot*er 40 mg )+ *r later# "ollo,ed by 40 mg on&e daily "or up to 14 days$ Gastric hypersecretory conditions)0 mg on&e daily initially; may be in&reased up to 120 mg . times daily (doses @+0 mg/day s*ould be

Client Dose 20 m' E ca-sule 1@s daily

1edication n0ormation Form Classi0ication ndication and Action T!er" Class" antiulcer a'ents !arm" Class" -roton -umin!i$itors ndications. ./RD/maintenance of !ealin' in erosi5e eso-!a'itis" XDuodenal ulcers (6it! or 6it!out antiinfecti5es for Kelico$acter -ylori*" XS!ort-term treatment of acti5e $eni'n 'astric ulcer" X at!olo'ic !y-ersecretory conditions% includin' Yollin'er-/llison syndrome" XReduction of ris4 of .) $leedin' in critically ill -atients" ETC+ XKeart$urn occurrin' Zt6ice/64" Actions. 0inds to an enJyme on 'astric -arietal cells in t!e -resence of acidic 'astric -K% -re5entin' t!e final trans-ort of !ydro'en ions into t!e 'astric lumen"

Side *00ects%Drug interactions

Side Effects: CNS: di88iness# dro,siness# "atigue# *eada&*e# ,ea-ness CV: &*est pain GI: a!do"inal pain# a&id regurgitation# &onstipation# diarr*ea# "latulen&e# nausea# vomiting # and E: *ypomagnesemia (espe&ially i" treatment duration A. mo De !: it&*ing# ras* "S: bone "ra&ture

Nursing Considerations and Contraindications

Nu sin$ Conside ationsB 0ssess patient routinely "or epigastri& or abdominal pain and "ran- or o&&ult blood in t*e stool# emesis# or gastri& aspirate$ Cont aindicationsB

XKy-ersensiti5ity X#actation+ Discontinue ome-raJole or discontinue $reastfeedin'" 1se Cautiously in+ X#i5er disease (dose T may $e necessary* XE0+ #actation+ edi+ Safety not esta$lis!ed in -re'nant or $reastfeedin' 6omen% or c!ildren S1 yr X atients usin' !i'!doses for U1 year (R ris4 of !i-% 6rist% or s-ine fractures*"

(Reference* Deglin@ )# H#@ ,allerand@ A# H#@ C Sanos7i@ C# A# (5010"# Davis's drug guide for nurses# (15th ed#"# Philadel&hia. F A Da2is

Drug3Drug XEme-raJole is meta$oliJed $y t!e CL >?0 enJyme system and may com-ete 6it! ot!er a'ents meta$oliJed $y t!is system" X&ay si'nificantly T effects of ataJana5ir and nelfina5ir (concurrent use not recommended*" X&ay R ris4 of $leedin' 6it! 6arfarin (monitor )NR/ T*"

C/0: NS. 111NC

26

given in divided doses ; #$%20 mg on&e daily "or up to 14 days$

Co#

T!era-eutic /ffect(s*+ XDiminis!ed accumulation of acid in t!e 'astric lumen 6it! lessened 'astroeso-!a'eal refluA" XKealin' of duodenal ulcers"

XPoriconaJole may R le5els" X&ay T t!e anti-latelet effects of clo-ido'rel2 a5oid concurrent use" X&ay R le5els of cilostaJol2 consider T dose of cilostaJol from 100 m' t6ice daily to ?0 m' t6ice daily" XRifam-in may T le5els and may T res-onse2 a5oid concurrent use" XKy-oma'nesemia R ris4 of di'oAin toAicity" Drug3Natural Products+ St" 8o!nNs 6ort may T le5els and may T res-onse2 a5oid concurrent use"

De'lin% 8" K"% Pallerand% ," K"% V Sanos4i% C" ," (2010*" Davis's drug guide for nurses" (12t! ed"*" !iladel-!ia+ ; , Da5is Co"

C/0: NS. 111NC

2:

1edication Generic C (rand Name (tamsulosin* ;lomaA

Dose Range
PO: (Adults) 0$4 mg on&e daily a"ter a meal; may be a"ter 24 ,- to 0$+ mg/day$

Client Dose 0"> m' ca-sule 1 ca-sule E 1@s daily

1edication n0ormation Form Classi0ication ndication and Action

T%e & Class& none assigned P%a !& Class& perip*erally a&ting antiadrenergi&s Indications: 2anagement o" out"lo, obstru&tion in male patients ,it* prostati& *yperplasia$ Actions: 7e&reases &ontra&tions in smoot* mus&le o" t*e prostati& &apsule by pre"erentially binding to alp*a1-adrenergi& re&eptors$ T%e apeutic Effect(s): 7e&reased symptoms o" prostati& *yperplasia (urinary urgen&y# *esitan&y# no&turia $

Side *00ects%Drug interactions Side /ffects+

CNS: di''iness# headache EENT: r*initis CV: ort*ostati& *ypotension GU: priapism# retrograde/diminis*ed e?a&ulation

Refe ence: 7eglin# C$ /$# (allerand# 0$ /$# D Eanos-i# 3$ 0$ (2010 $ Davis&s drug guide for nurses$ (12t* ed$ $ 1*iladelp*iaB ; 0 7avis 3o$

Drug3Drug XCimetidine may R $lood le5els and t!e ris4 of toAicity" XR ris4 of !y-otension 6it! ot!er -eri-!erally actin' antiadrener'ics (doAaJosin% -raJosin% teraJosin*2 concurrent use s!ould $e a5oided" XStron' CL 3,> in!i$itors and CL 2D6 in!i$itors may R $lood le5els (concurrent use s!ould $e a5oided"

Nursing Considerations and Contraindications Nursing Considerations. ,ssess -atient for sym-toms of -rostatic !y-er-lasia (urinary !esitancy% feelin' of incom-lete $ladder em-tyin'% interru-tion of urinary stream% im-airment of siJe and force of urinary stream% terminal urinary dri$$lin'% strainin' to start flo6% dysuria% ur'ency* $efore and -eriodically durin' t!era-y" X,ssess -atient for first-dose ort!ostatic !y-otension and synco-e" )ncidence may $e dose related" E$ser5e -atient closely durin' t!is -eriod and ta4e -recautions to -re5ent inFury" X&onitor inta4e and out-ut ratios and daily 6ei'!t% and assess for edema daily% es-ecially at $e'innin' of t!era-y" Re-ort 6ei'!t 'ain or edema" XRectal eAams -rior to and -eriodically

C/0: NS. 111NC

2C

t!rou'!out t!era-y to assess -rostate siJe are recommended" Contraindications. Ky-ersensiti5ity" 1se Cautiously in+ X atients at ris4 for -rostate carcinoma (sym-toms may $e similar*2 X atients under'oin' cataract sur'ery (R ris4 of intrao-erati5e flo--y iris syndrome*2 XSulfa aller'y"

De'lin% 8" K"% Pallerand% ," K"% V Sanos4i% C" ," (2010*" Davis's drug guide for nurses" (12t! ed"*" !iladel-!ia+ ; , Da5is Co"

C/0: NS. 111NC

29

1edication Generic C (rand Name (t!era-m--lus* Cerne5it 12

Dose Range E+ ,dult 1 dose unit ta$let% ca-sule day or amount recommended $y indi5idual manufac"

Client Dose 1 ta$let E 1@s daily 6it! $rea4fast

1edication n0ormation Form Classi0ication ndication and Action &ulti-5itamin ndications+ E+ Treatment and -re5ention of 5itamin deficiencies" S-ecial formulations are a5aila$le for -atients 6it! -articular needs% includin'+ [ renatal multi-le 5itamins (6it! lar'er doses of folic acid*% [ reconce-tional multi-le 5itamins% [&ulti-le 5itamins 6it! iron% [&ulti-le 5itamins 6it! fluoride% [&ulti-le 5itamins 6it! ot!er minerals or trace elements" ,ctions+ XContain fat-solu$le 5itamins (,% D% and /* and most 6atersolu$le 5itamins (0com-leA 5itamins 01% 02% 03% 0?% 06% 012% 5itamin C% $iotin% and folic acid*" T!ese 5itamins are a di5erse 'rou- of com-ounds necessary for normal 'ro6t! and de5elo-ment" &any

Side *00ects%Drug interactions Side *00ects+ )n recommended doses% ad5erse reactions are eAtremely rare .1+ urine discoloration (-re-arations 6it! 0 5itamins* &isc+ aller'ic reactions to -reser5ati5es% additi5es% or colorants
D u$'D u$ Large amounts o" vitamin 6 may inter"ere ,it* t*e bene"i&ial e""e&t o" levodopa$

Nursing Considerations and Contraindications Nursin' Considerations+

0ssess patient "or signs o" nutritional de"i&ien&y be"ore and t*roug*out t*erapy$ 1atients at ris- in&lude geriatri& patients and t*ose ,*o are debilitated# burned# or unable to ta-e oral nutrition and t*ose ,it* malabsorption syndromes or &*roni& al&o*olism$ To(icit) O*e dose: 4o!i&ity rarely o&&urs ,it* multivitamin preparations be&ause o" t*e small amounts per unit o" "at-soluble vitamins$ ;or symptoms# see individual vitamin entries$ '" overdose o&&urs# treatment in&ludes indu&tion o" emesis or gastri& lavage# &al&ium glu&onate '( i" *ypo&al&emi&# and maintenan&e o" *ig* urine output$ Cont aindicationsB 0ssess patient "or signs o" nutritional de"i&ien&y be"ore and t*roug*out t*erapy$ 1atients at ris- in&lude geriatri& patients and t*ose ,*o are debilitated# burned# or unable to ta-e oral nutrition and t*ose

References+
De'lin% 8" K"% Pallerand% ," K"% V Sanos4i% C" ," (2010*" Davis's drug guide for nurses" (12t! ed"*" !iladel-!ia+ ; , Da5is Co"

C/0: NS. 111NC

30

act as coenJymes or catalysts in numerous meta$olic -rocesses" X#iIuid -roducts do not contain folic acid" +hera&eutic *00ect(s". X E+ re5ention of deficiency or re-lacement in -atients 6!ose nutritional status is Iuestiona$le" X)P+ Re-lacement in -atients 6!o are una$le to in'est oral feedin's or 5itamins"

,it* malabsorption syndromes or &*roni& al&o*olism$ To(icit) O*e dose: 4o!i&ity rarely o&&urs ,it* multivitamin preparations be&ause o" t*e small amounts per unit o" "at-soluble vitamins$ ;or symptoms# see individual vitamin entries$ '" overdose o&&urs# treatment in&ludes indu&tion o" emesis or gastri& lavage# &al&ium glu&onate '( i" *ypo&al&emi&# and maintenan&e o" *ig* urine output$

De'lin% 8" K"% Pallerand% ," K"% V Sanos4i% C" ," (2010*" Davis's drug guide for nurses" (12t! ed"*" !iladel-!ia+ ; , Da5is Co"

C/0: NS. 111NC

31

1edication Generic C (rand Name lantano&rost (?alatan"

Dose Range 1 dro- of 0"00?D solution once daily in t!e e5enin'

Client Dose 1 dro- 2@s daily in $ot! eyes

1edication n0ormation Form Classi0ication ndication and Action rosta'landin &ana'ement of o-en-an'le 'laucoma (increase of outflo6 of aIueous !umor*

Side *00ects%Drug interactions #ocal irritation% forei'n $ody sensation% increase eyelas! 'ro6t!% increase $ro6n -i'mentation in iris

Nursing Considerations and Contraindications t" s!ould 6as! $ot! !ands $efore eac! use of DorJolamide or any ot!er eye medication to -re5ent contamination of t!e eye" Contact lenses s!ould $e remo5ed" T!e !ead is tilted $ac4% and t!e lo6er eyelid is -ulled do6n 6it! t!e indeA fin'er to form a -ouc!" T!e $ottle is sIueeJed sli'!tly to allo6 t!e -rescri$ed \ of dro-s into t!e -ouc!" T!e tiof t!e dro--er s!ould not touc! t!e eye or eyelid" T!e eye t!en is closed 'ently for one to t6o minutes 6it!out $lin4in'"

De'lin% 8" K"% Pallerand% ," K"% V Sanos4i% C" ," (2010*" Davis's drug guide for nurses" (12t! ed"*" !iladel-!ia+ ; , Da5is Co"

C/0: NS. 111NC

32

Attach a medication in0ormation sheet including generic and trade name@ classi0ication@ dosage range@ route@ indication and actions@ contraindications@ side e00ects@ drug interactions@ and nursing considerations and contraindications# 1edication Generic C (rand Name (sertraline" Jolo0t Dose Range De-ression/ECD E+ (,dults* ?0 m'/day as a sin'le dose in t!e mornin' or e5enin' initially2 after se5eral 6ee4s may $e R at 6ee4ly inter5als u- to 200 m'/day% de-endin' on res-onse" E+ (C!ildren 13=1: yr*+ ECD=?0 m' once daily" E+ (C!ildren 6=12 yr*+ ECD=2? m' once daily" anic Disorder E+ (,dults* 2? m'/day initially% may R after 1 64 to ?0 m'/day" TSD E+ (,dults* 2? m' once daily for : days% t!en R to ?0 m' once daily2 may t!en
C/0: NS. 111NC

Client Dose ?0 m' 1 ta$let E 1@s daily

1edication n0ormation Form Classi0ication ndication and Action T!er" Class" antide-ressants !arm" Class" selecti5e serotonin reu-ta4e in!i$itors SSR)s ndications. X&aFor de-ressi5e disorder" X anic disorder" XE$sessi5ecom-ulsi5e disorder (ECD*" X ost-traumatic stress disorder ( TSD*" XSocial anAiety disorder (social -!o$ia*" X remenstrual dys-!oric disorder ( &DD*" Actions. )n!i$its neuronal u-ta4e of serotonin in t!e CNS% t!us -otentiatin' t!e acti5ity of serotonin" Kas little effect on nore-ine-!rine or do-amine"

Side *00ects%Drug interactions Side e00ects+ Drug3Drug X Serious% -otentially fatal reactions (!y-ert!ermia% ri'idity% myoclonus% autonomic insta$ility% 6it! fluctuatin' 5ital si'ns and eAtreme a'itation% 6!ic! may -roceed to delirium and coma* may occur 6it! concurrent &,E in!i$itors" &,E in!i$itors s!ould $e sto--ed at least 1> days $efore sertraline t!era-y" Sertraline s!ould $e sto--ed at least 1> days $efore &,E in!i$itor t!era-y" X&ay R -imoJide le5els and t!e ris4 of -otentially lifet!reatenin' cardio5ascular reactions" XDru's t!at affect serotoner'ic neurotransmitter systems% includin'

Re0erences.
De'lin% 8" K"% Pallerand% ," K"% V Sanos4i% C" ," (2010*" Davis's drug guide for nurses" (12t! ed"*" !iladel-!ia+ ; , Da5is Co"

T!era-eutic /ffect(s*+ X,ntide-ressant action" XDecreased incidence of -anic attac4s" XDecreased o$sessi5e

Nursing Considerations and Contraindications Nursing Considerations+ ,ssess for suicidal tendencies% es-ecially durin' early t!era-y" Restrict amount of dru' a5aila$le to -atient" Ris4 may $e increased in c!ildren% adolescents% and adults ]2> yr" ,fter startin' t!era-y% c!ildren% adolescents% and youn' adults s!ould $e seen $y !ealt! care -rofessional at least 6ee4ly for > 64% e5ery 3 64 for neAt > 64% and on ad5ice of !ealt! care -rofessional t!ereafter" X&onitor a--etite and nutritional inta4e" <ei'! 6ee4ly" Notify !ealt! care -rofessional of continued 6ei'!t loss" ,dFust diet as tolerated to su--ort nutritional status" X ,ssess for serotonin syndrome (mental c!an'es ^a'itation%

33

$e R if needed at inter5als of at least : days (ran'e ?0=200 m' once daily*" Social ,nAiety Disorder E+ (,dults* 2? m' once daily initially% t!en ?0 m' once daily2 may $e R at 6ee4ly inter5als uto 200 m'/day" &DD E+ (,dults* ?0 m'/day initially eit!er daily or daily durin' luteal -!ase of cycle" Daily dosin' may $e titrated u-6ard in ?0-m' increments at t!e $e'innin' of a cycle" )n luteal -!ase=only dosin' a ?0 m'/day titration ste- for 3 days at t!e $e'innin' of eac! luteal -!ase dosin' -eriod s!ould $e used (ran'e ?0=1?0 m'/day*"

and com-ulsi5e $e!a5ior" XDecreased feelin's of intense fear% !el-lessness% or !orror" XDecreased social anAiety" XDecrease in -remenstrual dys-!oria"

lineJolid% tramadol% tri-tans% and fentanyl R ris4 of serotonin syndrome" X&ay R sensiti5ity to adrener'ics and R t!e ris4 of serotonin syndrome" XConcurrent use 6it! alco!ol is not recommended" XCimetidine R $lood le5els and effects" Dru'-Natural roducts+ R ris4 of serotiner'ic side effects includin' serotonin syndrome 6it! St" 8o!nNs 6ort and S,&e"

!allucinations% coma_% autonomic insta$ility ^tac!ycardia% la$ile 0 % !y-ert!ermia_% neuromuscular a$errations ^!y-errefleAia% incoordination_% and/or .) sym-toms ^nausea% 5omitin'% diarr!ea_*% es-ecially in -atients ta4in' ot!er serotoner'ic dru's (SSR)s% SNR)s% tri-tans*" Contraindications. XKy-ersensiti5ity XConcurrent &,E in!i$itor t!era-y (may result in serious% -otentially fatal reactions* XConcurrent -imoJide XEral concentrate contains alco!ol2 a5oid in -atients 6it! 4no6n intolerance" 1se Cautiously in+ XSe5ere !e-atic or renal im-airment X atients 6it! a !istory of mania XKistory of suicide attem-t

De'lin% 8" K"% Pallerand% ," K"% V Sanos4i% C" ," (2010*" Davis's drug guide for nurses" (12t! ed"*" !iladel-!ia+ ; , Da5is Co"
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Attach a medication in0ormation sheet including generic and trade name@ classi0ication@ dosage range@ route@ indication and actions@ contraindications@ side e00ects@ drug interactions@ and nursing considerations and contraindications# 1edication Generic C (rand Name (DorIolamide" +imolol Dose Range Not to eAceed more t!an > dro-s daily eac! eye Client Dose 1 dro- eac! eye 2@s daily 1edication n0ormation Form Classi0ication ndication and Action Car$onic an!ydrase in!i$itor
Indications: 2anagement o" openangle glau&oma or ot*er "orms o" o&ular *ypertension ( "ormation o" aqueous *umor $ Actions:

Side *00ects%Drug interactions Side e00ects.

Eystemi& absorption may result in adverse &ardiovas&ular and 3>E rea&tions (espe&ially in patients ,it* &ardiovas&ular disease ; avoid use in patients predisposed to a&ute angle-&losure glau&oma$ D u$ to D u$B F*en used ,it* ot*er eye drops "or redu&ing intrao&ular pressure# administration o" bot* drugs s*ould be separated by at least 10 minutes$

Nursing Considerations and Contraindications t" s!ould 6as! $ot! !ands $efore eac! use of t!is dru'" To -re5ent contamination of t!e eye do not touc! ti- of eye drocontainer to surface of t!e eye or any ot!er surface" Ta4e contact lenses out $efore a--lyin' eye dro-s" Close eye for one to t6o minutes after a--lyin' dru' 6it!out $lin4in'"

De'lin% 8" K"% Pallerand% ," K"% V Sanos4i% C" ," (2010*" Davis's drug guide for nurses" (12t! ed"*" !iladel-!ia+ ; , Da5is Co"

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N'RS NG CAR* AND +R*A+1*N+S

*4am&les o0 treatments. Dressings@ irrigations@ incenti2e s&irometer@ CP1 a&&lication@ A, or SCD !oots@ s&lints

1* Pitals daily+ com-are 6it! $aseline* 2* S4in assessment daily+ assess for -ressure ulcers% s4in irritation% lesions% etc"* 3* ain scale daily+ assess -t" le5el of -ain* >* Dressin' c!an'e daily2 left !eal -ressure ulcer -resent a" Aerofom 'auJe -lus $anda'e daily until !ealed $" air $oot to $e a--lied to left foot 6!ile in $ed ?* ressure reduced mattress+ -re5entati5e measure used to reduce incidence of -ressure ulcers 6* <!eel c!air+ utiliJed to aid -t" in am$ulation :* !ysical re!a$ilitation t!era-y+ 2@s 6ee4ly to restore stren't! in ri'!t !iand le' r/t ri'!t !i- fracture 06/06/2013 C* syc!olo'ical counselin'+ 2@s 6ee4 for de-ression r/t ina$ility to return to -re5ious residence $ecause -t" is una$le to -erform daily ,D#s inde-endently at -resent time 9* S!o6er c!air for assistance 6!en $at!in'

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PrioritiIation o0 nursing concerns /ist all nursing concerns in order o0 &riorit$# Note+ )t is eA-ected t!at if a -ro$lem is listed as num$ers 1% 2% or 3 t!at t!ese -ro$lems 6ould $e addressed in t!e Care lan" ,t least one -ro$lem s!ould $e related to t!e -at!o-!ysiolo'y% eAam-le+ if t!e care -lan is a !eart -atient% at least one nursin' dia'nosis s!ould $e related to t!e !eart disorder"

1* Ris4 for as-iration and ineffecti5e air6ay clearance r/t im-aired s6allo6in' from neuromuscular dysfunction 2* C!ronic -ain r/t !i- fracture 06/2013 ,/0 -t" self-states -ain le5el on scale of 0-10 at : and often recorded in c!art 3* Ris4 for fall+ Ris4 factor+ im-aired -!ysical mo$ility in lo6er eAtremities r/t -ain due to ri'!t !i- fracture and !istory of falls >* Ris4 for ad5anced de5elo-ment of decreased cardiac out-ut r/t increased 5ascular resistance% !y-ertension% arteriosclerosis ?* Ris4 for )nfection r/t -resent -ressure ulcer 6* )m-aired -!ysical mo$ility r/t decrease stren't! and endurance secondary to !i- fracture as e5idence -t" statement of -ain 6!en tryin' to am$ulate on ri'!t le' :* De-ression r/t -resent !o-elessness of li5in' in #TC facility ,/0 t" statin' 6antin' to 'o !ome" C* ;ati'ue r/t slee- ,/0 -t" statin' t!at -ain in ri'!t u--er le' and !i- area 4ee-s !im a6a4e many ni'!ts 9* Slee- de-ri5ation r/t -rolon'ed -!ysical discomfort ,/0 -t" statin' -ain in ri'!t !i- causes slee-lessness many ni'!ts 10* Ris4 for com-romised Resilience 11* Ris4 for )m$alanced Nutrition+ less t!an $ody reIuirements r/t 6ei'!t 20D less ideal for !ei'!t and frame

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Ris4 for as-iration and ineffecti5e air6ay clearance r/t im-aired s6allo6in' from neuromuscular dysfunction
Nursing Diagnosis. 1" ,alidating Assessment Factors. (T!is is to REP/ t!at a Nursin' Dia'nosis is necessary to resol5e t!is -ro$lem"*

t" self-re-orts difficulty s6allo6in' food and liIuid due to -re5ious incidence of &) 0:/200:" C!art reflects incidence of as-iration initiatin' fall resultin' in ri'!t !i- fracture 06/2013" t" self-re-orts incident 6as r/t ineffecti5e air6ay clearance due to as-iration and ina$ility to s6allo6 effecti5ely" C!art reflects t!era-y initiated 6it! s-eec! t!era-ist 06/2013 to increase -t" a$ility to effecti5ely s6allo6 and -re5ent as-iration" C!art reflects -t" attended t!era-y 2@s 6ee4ly and -ro'ress 6as noted as -ositi5e" t" states !e declined to continue to attend s-eec! t!era-y 10/2013% statin' !e did not feel li4e it 6as effecti5e alt!ou'! !e continues to eA-erience im-aired s6allo6in' a$ility" C!art reflects -!ysicians reIuest !e continue s-eec! t!era-y to aid in -t" a$ility to effecti5ely s6allo6 and -re5ent current and future as-iration e-isodes" t" self-re-orts non-com-liance to attend s-eec! t!era-y" t" 6ill eA-ress understandin' of t!e need to resume s-eec! t!era-y to aid in increased a$ility to s6allo6 t!us -re5entin' current and future as-iration e-isodes and recommence t!era-y sessions $y end day"
Goal. Actions 6ith rationale. (&inimum of t!ree*

1" /ncoura'e -t" to eA-ress current attitude concernin' -ast eA-erience 6it! s-eec! t!era-y in5ol5ement and -t"s reasons for non-com-liance" ,llo6in' -t" to eA-ress feelin's concernin' unsatisfactory results relatin' to -ro'ress of increased s6allo6in' a$ility and !is lac4 of need to continue t!era-y ac4no6led'es -t" concerns and aids in $etter understandin' of reasons for non-com-liance to t!era-y" 2" /ducate -t" on im-ortance of attendin' s-eec! t!era-y to im-ro5e s6allo6in' a$ility and decrease incidences of as-iration t!at can lead to future accidents and inFuries" Communicate to -t" t!e ris4s r/t as-irations concernin' restricted air6ay clearance and ina$ility to $e a$le to $reat!e t!at can lead to increased falls and -ossi$ly deat!" Ka5e -t" re-eat and relate to education tau'!t and si'nificance of increasin' s6allo6in' a$ility" 3" resent -ossi$le resolutions and modifications to -t"s concerns re'ardin' incon5enient t!era-y times and eAcessi5e 6ee4ly t!era-y a--ointments t!at -t" states is often o5er6!elmin' and tedious" /ncoura'e -t" to -ro-ose desira$le adFustments a--lica$le t!at 6ould increase !is desire to resume and -artici-ate -roducti5ely in t!era-y" roducti5ely in5ol5in' -t"s
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3C

su''estions to modify !is concerns re'ardin' t!era-y to aid in meetin' !is -ersonal needs -romotes -t" to as-ire -roducti5ely -artici-ate in t!era-eutical re!a$ilitation" )n addition% t!is confirms to t!e -t" t!at !is concerns are 5alid" Contact s-eec! t!era-ist to discuss -t" concerns" )nstruct -t" on !o6 to contact s-eec! t!era-ist to resume needed s-eec! t!era-y and encoura'e -t" to address concerns stated for non-com-liance to s-eec! t!era-ist to aid in -ossi$le modifications discussed"
*2aluation. (<as 'oal ac!ie5ed or notM )f not% are t!ere any actions 6!ic! could !el- ac!ie5e t!at 'oalM )s it a--ro-riate to 4ee- 6it! t!e ori'inal -lanM*

11/12/2013 0C00 t" ac!ie5ed 'oal $y eA-ressin' reasons for non-com-liance to t!era-y" t" states !is im-ression of -ro'ress to t!era-y 6as unmeasura$le in increasin' s6allo6in' a$ility" t" states feelin' a''ra5ation and disa--ointment of -ro'ress ac!ie5ed r/t t!era-y" t" eA-ressed sc!eduled time for t!era-y eac! 6ee4 to $e ill-timed 6it! -t" need for relaAation -eriod after lunc!" t" eA-resses attendin' multi-le t!era-y sessions 6ee4ly (-!ysical t!era-y 2@s 6ee4ly% -syc!olo'ical t!era-y 2@s 6ee4ly% and s-eec! t!era-y 2@s 6ee4ly* is often o5er6!elmin' and tiresome for !im" 11/12/2013 1100 t" ac!ie5ed 'oal $y re-eatin' teac!in' on t!e im-ortance of im-ro5in' s6allo6in' a$ility and dan'ers in5ol5ed re'ardin' as-iratin'" t" understands and admits t!at attendin' s-eec! t!era-y can aid in im-ro5in' !is s6allo6in' a$ility and decrease dan'er r/t as-iration" 11/12/2013 1?00 t" ac!ie5ed 'oal $y -ro-osin' modification to current s-eec! t!era-y time from 1230 to 1>30 allo6in' -t" to recei5e needed rest after mornin' acti5ities and lunc!" t" -ro-osed modification to current s-eec! t!era-y sc!eduled days (2@s 6ee42 &onday and Tuesday* to $e resc!eduled to &onday and ;ridays t!us decreasin' feelin's of $ein' o5er6!elmed 6it! demands r/t t!era-y" To increase -t" desire to continue 6it! s-eec! t!era-y -t" su''ests im-ro5in' communication 6it! s-eec! t!era-ist to clarify -t" -ro'ress and 6ays -t" can -ractice tec!niIues 6!en not in t!era-y" t" met 6it! s-eec! t!era-ist% eA-ressed concerns% adFustments made to t!era-y sc!edulin' -er -t"s reIuests" t" is sc!eduled to resume s-eec! t!era-y 11/1>/2013% 1>30"

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39

('S* S*PARA+* SH**+ F-R *ACH N'RS NG D AGN-S S"

Nursing Diagnosis. C!ronic -ain r/t !i- fracture 06/2013 ,/0 -t" self-states -ain le5el on scale of 0-10 at : and often recorded in c!art 9
,alidating Assessment Factors.
(T!is is to REP/ t!at a Nursin' Dia'nosis is necessary to resol5e t!is -ro$lem"*

t" self -states -ain le5el on scale of 0-10 at :" C!art reflects -t" suffered a fall t!at resulted in a fracture of t!e -roAimal femur $one to ri'!t lo6er eAtremity (!ifracture* 06/2013" t" states ina$ility to $are 6ei'!t on ri'!t le' due to -ain in ri'!t !i- and u--er ri'!t le'" t"s a$ility to am$ulate currently is restricted to 6!eelc!air mo$ility only" t" states -ain intensity often a6a4ens !im at ni'!t and disru-ts !is normal slee- -atterns" t" currently attends re!a$ilitation -!ysical t!era-y 2@s 6ee4ly" C!art reflects -t" -!ysical t!era-y results as 3slo6 -ro'ression7 due to -t" com-laints of -ain in ri'!t le' 6!en attem-tin' to -erform t!era-eutic eAercises" C!art reflects additional factor in t!e slo6 -ro'ress of -t -!ysical t!era-y results is r/t t!e -t" un6illin'ness to -ro'ressi5ely increase RE& or attem-t to $ear any 6ei'!t on ri'!t le'" t" !as im-aired a$ility to s6allo6 -roducti5ely resultin' in decreased a$ility to consume needed nutrients for -ro-er $one !ealin'2 c!art recordin' states -t" current 6ei'!t reflects a 6ei'!t loss of >0 l$s" since admission% !o6e5er% -t" !as resumed to 'radually 'ainin' 6ei'!t in t!e last mont!"

Goal. 11/1:/2013 t" 6ill self-re-ort t!e im-ortance of consumin' needed calories

and nutrients to -romote !ealt!y $one !ealin'" t" 6ill eAercise non--!armacolo'ic inter5entions to relie5e -ain" t" 6ill eA-ress and self-re-ort 6ays to eAercise outside of -!ysical t!era-y sessions t!us increasin' muscle stren't! and increasin' am$ulation" t" 6ill eA-ress decrease in -ain le5el from current -ain le5el of : to less t!an or eIual to ? usin' -ain scale 0-10" t" t" 6ill com-lete 'oals $y 11/19/2013
Actions 6ith rationale. (&inimum of t!ree*

1" ,ssess -t" current diet" ,ssess foods t!at a--eal to -t" or t!at -t" -refers to eat" /ducate -t" on t!e im-ortance of consumin' adeIuate calories and nutrients to aid in -ro-er !ealin' of -t" $ones" /A-ress consumin' foods !i'! in calcium and ma'nesium li4e s4im mil4% yo'urt% $roccoli% carrots and oatmeal can increase $one !ealin'" .i5e -t" list of foods t!at -romote $one !ealin' so -t" can c!oose foods on list to add or su$stitute in !is current diet" /A-lain to -t" t!ese foods also -romote !ealt!y $ody tissue formation and 6it! eAercise can -romote increase in muscle mass and can contri$ute to increasin' stren't! in !is left le'" <ei'! -t" daily and com-are to $ase line
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6ei'!t to assess if furt!er 6ei'!t loss -attern is recurrin' Contact dietitian to meet 6it! -t" to !el- 6it! meal -lannin' to add foods su''ested" Ka5e -t" re-eat teac!in' and understandin'" 2" ,ssess -t" current re'ime for eAercise 6!en not in -!ysical t!era-y" /ducate -t" on non--!armacolo'ic met!ods to relie5e -ain" /A-lain t!at listenin' to music -t" enFoys or mental ima'ery eAercises can decrease -ain sensations" ,--lyin' !eat/cold can aid to relie5e -ain and ele5ation or re-ositionin' can sometimes relie5e -ain" .i5e -t" instructions on 6ays to eAercise 6!ile sittin' in 6!eelc!air $y doin' small le' lifts" /A-lain t!at t!is 6ill $uild muscle 'radually 6it!out eAcessi5e 6ei'!t $arin' to le'" Ka5e -t" re-eat learnin' and demonstrate 6!eelc!air eAercises and non-!armacolo'ic -ain relie5in' eAercises" 3" ,ssess -ain le5el 6!ile -erformin' eAercise in t!era-y and outside of t!era-y" ,ssess location% Iuality and Iuantity of -ain" ,ssess 6!en and if -ain is more or less at different occurrences or times of day" /ducate t!e -t" on -ro-er communication of eA-ressin' -ain" /ncoura'e -t" to 4ee- a diary of -ain scale recordin's to com-are if -ain is increasin' or declinin'" /ducate -t" to re-ort increasin' -attern of -ain to !ealt! care -ro5ider"

*2aluation. (<as 'oal ac!ie5ed or notM )f not% are t!ere any actions 6!ic! could !el- ac!ie5e t!at 'oalM Er% is it a--ro-riate to 4ee- 6it! t!e ori'inal -lanM*

11/1:/2013 0900 t" met 'oals" t" self-re-orted foods t!at increase and -romote $one !ealin' and met 6it! dietitian 11/1:/2013 1300 to -lan menu to add foods su''ested to current food inta4e" t" self-re-orted and demonstrated -ro-er 6!eelc!air eAercises and non--!armacolo'ic met!ods to decrease -ain" t" stated understandin' t!e im-ortance of t!ese eAercises are -romote muscle $uildin' and decrease -t" -ain le5el" 11/19/2013 0900 t" met 'oal" t" re-orted ? on -ain scale of 0-10" <ill continue to monitor -ro'ress" t" is maintainin' current 6ei'!t of 133 l$s" 0930 11/19/2013"

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>1

Nursing Diagnosis. Ris4 for fall+ Ris4 factor+ im-aired -!ysical mo$ility in lo6er

eAtremity r/t -ain due to ri'!t !i- fracture and !istory of falls
,alidating Assessment Factors. (T!is is to REP/ t!at a Nursin' Dia'nosis is necessary to resol5e t!is -ro$lem"*

t" is una$le to -erform daily ,D#s 6it!out full !uman assistance" t" suffered a fall resultin' in ri'!t !i- fracture 06/2013" t" is una$le to am$ulate2 use of 6!eel c!air for mo$ility" t" self-re-orts ina$ility to stand or $are any 6ei'!t on ri'!t le'" t" needs full assistance for transferrin' from $ed to c!air% 6!eelc!air to toilet% and ta4in' s!o6er usin' s!o6er c!air" C!art reflects am$ulation as 1 on scale of 1> and transferrin' as a 1 on scale of 1-> Ecto$er 2013" t" 6ill understand and recite t!e im-ortance to o$tain assistance 6!en need arises to am$ulate" t" 6ill understand% demonstrate% and recite safety -recautions for o-eratin' 6!eelc!air" t" 6ill meet 'oal $y end of day"
Goal. 11%50%501K t" 6ill remain free of falls"

Actions 6ith rationale. (&inimum of t!ree*

1" Teac! -t" im-ortance of o$tainin' !uman assistance 6!en assistance is needed in all ,D#s to minimiJe incidence of falls and inFury" Teac! -t" not to attem-t to am$ulate 6it!out assistance eA-lainin' t!is could cause furt!er inFury to eAistin' ri'!t !i- fracture and in addition could also result in addition inFuries" 2" /ducate -t" on -ro-er use of 6!eelc!air" Teac! -t" 6!en not mo$ile to ma4e sure 6!eel $rea4s are in loc4ed -osition" Teac! 6!ile mo$ile in 6!eelc!air -ay s-ecial attention to s-illed su$stance or 6et floors t!at could cause 6!eels to sli- or 6!eelc!air to slide and -ossi$ly fli- o5er causin' inFury" Teac! -t" to ne5er attem-t to na5i'ate stee- slo-es alone and do not try to reac! for an o$Fect if you !a5e to mo5e to t!e ed'e of t!e seat to reac! it" )n addition to t!is% teac! -t" not to reac! for an o$Fect $et6een your le's" /A-lain t!at t!ese acti5ities may cause you to fall out of your c!air and on to t!e floor" Ka5e -t" re-eat and demonstrate learnin'" 3" Ka5e call li'!t assessa$le at all times so -t" can alert staff 6!en in need of assistance" T!is 6ill -re5ent incidents of -t" falls" &a4e sure at all-times -t" !as c!air and $ed monitor alarms -resent and o-eratin' -ro-erly to notify staff 6!en/if -t" !as fallen or is attem-tin' to am$ulate 6it!out assistance"
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*2aluation.
(<as 'oal ac!ie5ed or notM )f not% are t!ere any actions 6!ic! could !el- ac!ie5e t!at 'oalM Er% is it a--ro-riate to 4ee- 6it! t!e ori'inal -lanM*

11/20/2013 1>00 t" met 'oals $y recitin' and demonstratin' instructions learned for -ro-er 6!eelc!air safety and o-eration" t" recited im-ortance of instructions tau'!t -ertainin' to -t"s necessity to call for assistance 6!en needin' to -erform all ,D#s" t" self-re-eats t!e im-ortance of not attem-tin' to am$ulate on o6n" t" call li'!t o$ser5ed assessa$le 6it!in -t" reac! 6!ile in 6!eelc!air and 6!ile in $ed" E$ser5ed c!air and $ed alarm in -lace and 6or4in' -ro-erly" <ill continue to monitor -t" -ro'ress"

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>3

R/;/R/NC/S

,dams% &"% Kolland% #"% V 1r$an % C" (200C*" Pharmacolog for nurses" (>t! ed"% --" 139-1>0*" 1--er Saddle Ri5er + earson" )'nata5icius% D"% V <or4man% &" #" (2012*" !edical "surgical nursing# Pa$ien$"cen$ered collabora$ive care" (: ed"% Pol" 2*" St" #ouis% &issouri+ /lse5ier-Saunders" De'lin% 8" K"% Pallerand% ," K"% V Sanos4i% C" ," (2010*" Davis's drug guide for nurses" (12t! ed"*" !iladel-!ia+ ; , Da5is Co" ,c4ley% 0" 8"% V #ad6i'% ." 0" (201>*" %ursing diagnosis handboo& an evidence"based guide $o 'lanning care" (10t! ed"*" St" #ouis%&issouri+ &os$y /lse5ier" a'ana% G" D"% V a'ana% T" 8" (2010*" !osb' s manual of diagnos$ic and labora$or $es$s( (> ed"*" St" #ouis% &E+ &os$y )nc" )'nata5icius% D"% V <or4man% &" #" (2013*" !edical "surgical nursing# Pa$ien$"cen$ered collabora$ive care)clinical com'anion" (: ed"% Pol" 2*" St" #ouis% &issouri+ /lse5ier-Saunders" 8ar5is% C"% (2012*% Ph sical e*amina$ion +heal$h assessemen$( (6t! ed"*% St" #ouis% &issouri+ /lse5ier-Saunders" Penes% D" (2009*% Taber,s c clo'edic medical dic$ionar ( (22nd ed"*% 1S,% ;", Da5is Com-any"

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