Term Paper on "Care Plan for Patient"

Term Paper 10 pages (5079 words) Sources: 10

[EXCERPT] . . . .

7

12.0-20.0

Within Range

Glucose

98

70-105

Within Range

BUN

22

7-25

Within Range

Creatinine

0.93

0.6-1.3

Within Range

B/C Ratio

23.7

8.0-25.0

Within Range

Calcium

8.69

8.5-10.8

Within Range

ALT (SGPT)

8

7-52

Within Range

AST (SGOT)

18

13-39

Within Range

Alkaline Phosphate

63

34-104

Within Range

Total Bilirubin

1.5 (high)

0.3-1.4

Patient may be experiencing hemolytic anemia or problems with the liver.

Total Protein

5.9 (low)

6.0-8.3

Low total protein may signal malabsorption, malnutrition, and or liver/kidney problems.

Albumin

3.37 (low)

3.5-5.7

Low albumin may be caused by a poor nutrition state or congestive heart failure or kidney dysfunction.

Globulin

<br />

2.5

2.2-4.2

Within Range

A/G Ratio

1.3

0.8-2.0

Within Range

GFR Caucasian

77

>60 ml/min/1

Within Range

GFR African-American

93

>60 ml/min/1

Within Range

WBC

7.5

4-11

Within Range

RBC

4.03 (low)

4.1-6.2

This anemia could be caused by chronic inflammatory disease or a combination of nutritional deficiency and kidney failure.

Hemoglobin

12.4 (low)

13.5-17.5

May indicate anemia from cirrhosis.

Hematocrit

37.8 (low)

41-53

This anemia could be caused by malnutrition, as in low vitamin b12 levels or cancer.

MCV

94

80-97

Within Range

MCH

30.9

26-32

Within Range

MCHC

33.0

32-37

Within Range

RDW

14.3

11.5-14.5

Within Range

Platelet Count

130-400

Within Range

Neutrophil %

56.4

40-74

Within Range

Lymphocyte %

27.6

19-48

Within Range

Monocyte %

10.8

2-11

Within Range

Eosonophil %

4.1

0-7

Within Range

Basophil %

1.1

0-1.5

Within Range

Neutrophil #

4.3

1.7-7.7

Within Range

Lymphocyte #

2.1

1-4.8

Within Range

Monocyte #

0.8

0-1

Within Range

Eosinophil #

0.3

0.04-0.45

Within Range

Basophil #

0.1

0.00-0.20

Within Range

Medications:

The patient is taking Norvasc because they have a history of high blood pressure.

DRUG

Generic name and trade name

DOSE, ROUTE,

FREQUENCY,

Therapeutic Dose

MOA

DRUG CLASS

INDICATION

Carvedilol Oral Tablet

(Coreg)

(Skidmore-Roth, 2015, p. 210).

25 MG, 1 Tab, PO, 2X Daily at 9AM and 5PM

Therapeutic dose

A combination of nonselective a-/b-adrenergic blocking activity; reduces cardiac output, exercise-induced tachycardia, reflex orthostatic tachycardia;

causes vasodilation, decrease in peripheral vascular resistance

Antihypertensive and adrenergic blocker

Essential hypertension alone/mixed with other antihypertensives,

CHF, cardiomyopathy

Finasteride Oral Tablet

(Propecia or Proscar)

(Skidmore-Roth, 2015, p. 507).

5 MG 1 Tablet PO 1X Daily at 9PM

Therapeutic dose

Inhibits development of BHP; Inhibits 5-a-reductase as well as decrease in DHT; DHT induces androgenic effects via binding to androgen receptors

within cell nuclei of prostate gland, liver, skin;

Hormone, androgen inhibitor,

hair stimulant

Male-pattern baldness

GuaiFENesin Oral Tablet

(Tussin/Alfen/Mucinex)

(Skidmore-Roth, 2015, p. 580).

400 MG 1 Tablet PO 3X Daily at 6AM, 2PM, 10PM

Therapeutic dose

Increases volume as well as decreases the viscosity of secretions in bronchi and trachea to enable secretion removal

Expectorant

Productive and nonproductive

Cough

Lisinopril Oral Tablet

(Prinivil, Zestril)

(Skidmore-Roth, 2015, p. 717).

20 MG 1 Tablet PO 1X Daily 9AM

Therapeutic dose

Inhibits

ACE, thereby inhibiting conversion of angiotensin I to angiotensin II; Selectively suppresses renin-angiotensin-aldosterone

system;

Antihypertensive, angiotensin-converting

enzyme 1 (ACE) inhibitor

Mild to moderate hypertension, adjunctive therapy of systolic CHF, acute

MI

Omeprazole Oral Capsule Delayed Release

(NexIUM)

(Skidmore-Roth, 2015, p. 884-885).

20 MG 1 Capsule 1X Daily at 6:30AM

Therapeutic dose

Suppresses gastric secretions by inhibiting hydrogen/potassium

ATPase enzyme system in gastric parietal cell; characterized as gastric acid pump inhibitor because it blocks the final step of acid production

Antiulcer

Gastroesophageal reflux disease

(GERD), adult/child/infant; severe erosive esophagitis, adult/child; treatment of active duodenal ulcers in combination

with antiinfectives for Helicobacter

pylori infection; long-term usefor hypersecretory conditions

Oxybutynin Chloride ER Oral Tablet Extended Release 24-Hour (Ditropan/Gelnique)

(Skidmore-Roth, 2015, p. 896).

5 MG 1 Tablet PO at 9PM

Therapeutic dose

Relaxes smooth muscles in urinary tract via inhibiting acetylcholine at postganglionic sites

Anticholinergic

Antispasmodic for neurogenic

Bladder

Phillips Colon Health Oral Capsule

(Skidmore-Roth, 2015, p. 738).

1 Capsule PO 1X Daily at 9AM

Therapeutic dose

Increases osmotic pressure by drawing fluid into the colon and neutralizing HCl

Electrolyte; anticonvulsant;

saline laxative, antacid

Constipation; Electrolyte

Pravastatin Sodium Oral Tablet

(Livalo)

(Skidmore-Roth, 2015, p. 968).

20 MG 1 Tablet PO at 9PM

Therapeutic dose

Inhibits HMG-CoA reductase enzyme, which reduces cholesterol synthesis;

high doses lead to plaque regression

Antilipidemic

As an adjunct for primary hypercholesterolemia

(types Ia, Ib), dysbetalipoproteinemia, elevated triglyceride levels, prevention of CV disease by reduction of heart risk in those with mildly elevated cholesterol

Tamsulosin HCL Oral Capsule

(Flomax)

(Skidmore-Roth, 2015, p. 1120).

0.4 MG 1 Capsule PO at 9PM

Therapeutic dose

Binds preferentially to-a1Aadrenoceptor

subtype, which is located mainly in the prostate

Selective a1-peripheral adrenergic blocker, BPH agent

Symptoms of benign prostatic?

hyperplasia?(BPH)

PRN Medications

Maalox Advanced Oral Suspension

(Calcium Carbonate)

(Skidmore-Roth, 2015, p. 186).

200-200-20 MG/5ML 20 Milliliter PO to Abdomen, Chest PRN 1X Daily

Neutralizes gastric acidity

Antacid, calcium supplement;

not suitable for chronic therapy, hyperphosphatemia, hypertension during

pregnancy, osteoporosis, prevention, treatment of hypocalcemia, hypoparathyroidism

Calcium Supplement, Antacid

Acetaminophen Oral Tablet

(Equaline/Tylenol)

(Skidmore-Roth, 2015, p. 8).

325 MG 3 Tablet PO PRN Every 6 Hours

Temporarily blocks pain impulses peripherally that happen in reaction to inhibition of prostaglandin synthesis; antipyretic action results from inhibition of prostaglandins in the CNS; does not have anti-inflammatory properties;

Nonopioid analgesic,

Antipyretic

Pain

Diazepam Oral Tablet

(Diazemuls, Diastat, Valium)

(Skidmore-Roth, 2015, p. 356).

2 MG 1 Tablet PO PRN Every 8 hours

Potentiates the actions of GABA, especially in the limbic system, reticular formation; enhances presympathetic inhibition, inhibits spinal polysynaptic afferent paths

Antianxiety, anticonvulsant skeletal muscle relaxant, central acting

Anxiety, acute alcohol withdrawal, adjunct for seizure disorders;

preoperatively as a relaxant for skeletal muscle relaxation; rectally for acute repetitive seizures

(bisacodyl)

Dulcolax Rectal Suppository

(Skidmore-Roth, 2015, p. 145).

10 MG 1 Suppository PER RECTUM PRN 1X Daily

Believed to exasperate colonic intramural plexus by acting directly on intestine via increased motor activity

Stimulant, laxative

Constipation

Fleet Mineral Oil Rectal Enema

(Skidmore-Roth, 2015, p. 386).

1 Application PER RECTUM PRN 1X Daily

Increases water, fat penetration in intestine; allows for easier passage of stool

Laxative, emollient;

stool softener

Prevention of dry, hard stools

Imodium A-D Oral Tablet

(loperamide) (Skidmore-Roth, 2015, p. 721).

2 MG 2 Tablet PO PRN Every 6 Hours

Direct action on intestinal

muscles to decrease GI peristalsis; reduces volume, increases bulk; electrolytes not lost

Antidiarrheal

Diarrhea

Meclizine HCL Oral Tablet

(Antivert/Bonine)

(Skidmore-Roth, 2015, p. 746).

25 MG 1 Tablet PO PRN Every 6 Hours

Acts centrally by blocking chemoreceptor trigger zone, which in turn acts on vomiting center

Antiemetic, antihistamine, anticholinergic

Motion Sickness, Vertigo

Milk of Magnesia Oral Suspension

(Skidmore-Roth, 2015, p. 738).

1200 MG/15ML 30 Milliliter PO PRN 1X Daily

Increases osmotic pressure and pulls fluid into colon, successfully neutralizing HCl

Antacid, electrolyte; saline laxative, anticonvulsant

Constipation

Ondansetron HCL Oral Tablet

(Zofran)

(Skidmore-Roth, 2015, p. 886).

4 MG 1 Tablet PO PRN Every 6 Hours

Prevents nausea, vomiting by blocking serotonin peripherally, centrally, and in the small intestine

Antiemetic

Prevention of nausea, vomiting

Other Diagnostic Tests:

Test

Results

Significance

04/04/16

CT Head/Brain w/o Contrast

Atrophy and ischemic microangiopathic changes are present with no acute intracranial hemorrhage Mass nor mass effect is seen.

Consistent with patient's diagnosis of syncope.

04/04/16 CTA Chest w/wo Contrast

There is no evidence of pulmonary embolus. The thoracic aorta is normal in caliber with no aneurysm or dissection demonstrated.

Stable atelectasis at the right lung base.

Cholelithiasis is present.

Right thyroid nodule is present.

Consistent with patient's diagnosis of syncope and AF.

04/05/16 CT Head/Brian w/o Contrast

No new acute intracranial abnormality including no acute hemorrhage or identifiable recent territorial infarct seen

Follow-up recent syncope and fall.

04/09/16 MRA Head w/o Contrast

No perfusion or diffusion weighted abnormality is seen. There is a tiny probable punctate old microhemorrhage in the posterior left centrum semiovale. There is cerebral atrophy and periventricular white matter small vessel ischemic changes. There is no evidence for acute territorial infarction or intra-cranial hemorrhage. No mass or midline shift is seen.

Left-sided weakness and suspected stroke.

04/09/16 MRI Brain w/wo Contrast

Atrophy and small vessel ischemic changes. No definite acute intracranial abnormality.

Normal MR angiography of the circle of Willis.

Left-sided weakness and suspected stroke.

04/09/16 U.S./VAS Duplex Carotid Arteries Bilateral

Calcified plaque without hemodynamically significant stenosis of the right internal carotid artery.

Calcified plaque without hemodynamically significant stenosis of the left internal carotid artery.

Patient is undergoing stroke evaluation.

Flow Chart: don't have to do the chart, please describe (not define) these terms, include references (not older than 5 years):

Cardiovascular Syncope

A very common occurrence among Americans, affecting over 3 million people a year, a cardiovascular syncope refers to when a person suddenly collapses or faints due to a malady of heart rhythm where there is an absent or slow pule leafing to fainting (syncope) without or with convulsions. Essentially, there is disruption in the normal heartbeat passing from the upper to the lower chambers of the heart; a sort of 'heart block'. Heart blocks results in considerably slow heart rates causing insufficient blood flow to a person's brain, resulting in syncope.

Hypertension

Hypertension is another name for high blood pressure. While people can have high blood pressure… READ MORE

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