Part 1 Objective: 1. Student nurse will develop and utilize information to assis
ID: 305459 • Letter: P
Question
Part 1
Objective:
1. Student nurse will develop and utilize information to assist patient at end of life.
2. Student will understand the reasons for an Advanced Directive.
Patient Information
NAME: Sarah Marshall
AGE: 43
DOB: October 15, 1974
WEIGHT: 101 lbs. (45.9 kg)
HEIGHT: 66 inches (170 cm)
Past Medical and Social History: Ms. Marshall has a past medical history (PMH) of metastatic breast cancer, anemia, and hypothyroidism. She was divorced in 2014 from her husband Kyle. She was on anti-depressive medications after the divorce, but she has been off of those for about a year. She has a daughter named, Dawn (age 22), and a son named Scott (age 18). Dawn is finishing up her nursing degree this fall, and Scott has recently graduated from high school and has enlisted in the Navy.
Situation: Ms. Marshall is a 43 year-old female that presented to the Emergency Room (ER) a few minutes before shift change. She was brought in by emergency medical services (EMS) for increasing shortness of breath, change in mental status as reported by her daughter, Dawn, and lethargy. Dawn is now at the bedside.
Plan of Care: Sarah will have an IV placed during shift change by IV Team. Nurse will obtain MD orders after provider assessment.
Current Medication List
Drug Classification, expected action, indication for use
Possible Adverse Effects
Medication or Food Interactions
Nursing Considerations
Client Education and Evaluation of Effectiveness
Omeprazole
Ferrous Sulfate
Docusate
Levothyroxine
Pre-Simulation Questions: (3-5 full sentences detailing needs of this patient)
1. What are the anticipated needs of this patient?
2. What are the key symptoms that led you to the above conclusion?
3. What is an advanced directive? What benefit is there to filling out this form?
CBC with Differential
What will this tell us?
What is the specific reason for this test for this patient?
Basic Metabolic Panel
Normal Range?
What is the reason for this test?
Part 2
Objective:
1. Student will work with interdisciplinary team to provide the best patient and family outcomes.
2. Student will follow Rasmussen Hospital Policy on body removal from the inpatient unit to the morgue.
3. Student will provide comfort to family by using therapeutic communication and assessing the needs of the family and meeting their needs.
4. Student will maintain a professional attitude that respects the wishes of the client along with addressing the concerns of family members.
Situation: Ms. Marshall is lethargic, but oriented. She is asked if she has an advanced directive. She stated that she does not as she was waiting until her son graduated from high school to “worry about these things”. The provider assessed the patient and decided meet with Dawn and Sarah, once Scott arrived at the hospital. During this meeting, it was decided by the family that Ms. Marshall shall change her code status to DNR/DNI. The family is very sorrowed by this choice, but know it is for the best as her condition is declining quickly. It has also been decided to complete and sign the following advanced directive. After her transfer to the medical floor for observation, Sarah is experiencing pain and would like medication. She also becomes increasingly distant and quiet, opening her eyes only when prompted.
MINNESOTA STATUTES 2017
145B.04 SUGGESTED FORM.
A living will executed after August 1, 1989, under this chapter must be substantially in the form in this section. Forms printed for public distribution must be substantially in the form in this section. "Health Care Living Will Notice: This is an important legal document. Before signing this document, you should know these important facts:
(a) This document gives your health care providers or your designated proxy the power and guidance to make health care decisions according to your wishes when you are in a terminal condition and cannot do so. This document may include what kind of treatment you want or do not want and under what circumstances you want these decisions to be made. You may state where you want or do not want to receive any treatment.
b) If you name a proxy in this document and that person agrees to serve as your proxy, that person has a duty to act consistently with your wishes. If the proxy does not know your wishes, the proxy has the duty to act in your best interests. If you do not name a proxy, your health care providers have a duty to act consistently with your instructions or tell you that they are unwilling to do so.
(c) This document will remain valid and in effect until and unless you amend or revoke it. Review this document periodically to make sure it continues to reflect your preferences. You may amend or revoke the living will at any time by notifying your health care providers.
(d) Your named proxy has the same right as you have to examine your medical records and to consent to their disclosure for purposes related to your health care or insurance unless you limit this right in this document.
(e) If there is anything in this document that you do not understand, you should ask for professional help to have it explained to you. TO MY FAMILY, DOCTORS, AND ALL THOSE CONCERNED WITH MY CARE: I, _____________________ born on _____________(birthdate), being an adult of sound mind, willfully and voluntarily make this statement as a directive to be followed if I am in a terminal condition and become unable to participate in decisions regarding my health care. I understand that my health care providers are legally bound to act consistently with my wishes, within the limits of reasonable medical practice and other applicable law. I also understand that I have the right to make medical and health care decisions for myself as long as I am able to do so and to revoke this living will at any time.
1 The following are my feelings and wishes regarding my health care (you may state the circumstances under which this living will applies): .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... ..........................................................................................................................................................................
2 I particularly want to have all appropriate health care that will help in the following ways (you may give instructions for care you do want): .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... ..........................................................................................................................................................................
3 I particularly do not want the following (you may list specific treatment you do not want in certain circumstances): .......................................................................................................................................................................... ..........................................................................................................................................................................
4 I particularly want to have the following kinds of life-sustaining treatment if I am diagnosed to have a terminal condition (you may list the specific types of life-sustaining treatment that you do want if you have a terminal condition): .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... ..........................................................................................................................................................................
5 I particularly do not want the following kinds of life-sustaining treatment if I am diagnosed to have a terminal condition (you may list the specific types of life-sustaining treatment that you do not want if you have a terminal condition): .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... ..........................................................................................................................................................................
6 I recognize that if I reject artificially administered sustenance, then I may die of dehydration or malnutrition rather than from my illness or injury. The following are my feelings and wishes regarding artificially administered sustenance should I have a terminal condition (you may indicate whether you wish to receive food and fluids given to you in some other way than by mouth if you have a terminal condition): .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... ..........................................................................................................................................................................
7 Thoughts I feel are relevant to my instructions. (You may, but need not, give your religious beliefs, philosophy, or other personal values that you feel are important. You may also state preferences concerning the location of your care.) .......................................................................................................................................................................... .......................................................................................................................................................................... .......................................................................................................................................................................... ..........................................................................................................................................................................
8 Proxy Designation. (If you wish, you may name someone to see that your wishes are carried out, but you do not have to do this. You may also name a proxy without including specific instructions regarding your care. If you name a proxy, you should discuss your wishes with that person.) If I become unable to communicate my instructions, I designate the following person(s) to act on my behalf consistently with my instructions, if any, as stated in this document. Unless I write instructions that limit my proxy's authority, my proxy has full power and authority to make health care decisions for me. If a guardian is to be appointed for me, I nominate my proxy named in this document to act as my guardian.
Name: ................................................................
Address: ............................................................
Phone Number: .................................................
Relationship: (If any) ........................................
If the person I have named above refuses or is unable or unavailable to act on my behalf, or if I revoke that person's authority to act as my proxy, I authorize the following person to do so:
Name: ................................................................
Address: ............................................................
Phone Number: .................................................
Relationship: (If any) ........................................
I understand that I have the right to revoke the appointment of the persons named above to act on my behalf at any time by communicating that decision to the proxy or my health care provider.
9 Organ Donation after Death. (If you wish, you may indicate whether you want to be an organ donor upon your death.) Initial the statement which expresses your wish:
_____In the event of my death, I would like to donate my organs. I understand that to become an organ donor, I must be declared brain dead. My organ function may be maintained artificially on a breathing machine, (i.e., artificial ventilation), so that my organs can be removed. Limitations or special wishes:
____________________________________________________________________________________________________________________________________________________________________________________________________
I understand that, upon my death, my next of kin may be asked permission for donation. Therefore, it is in my best interests to inform my next of kin about my decision ahead of time and ask them to honor my request.
I (have) (have not) agreed in another document or on another form to donate some or all of my organs when I die.
_____I do not wish to become an organ donor upon my death.
DATE: ............................................................... SIGNED: ........................................................... STATE OF ............................................................................COUNTY OF .................................................... Subscribed, sworn to, and acknowledged before me by ......................on this ........ day of ..................................................
NOTARY PUBLIC OR (Sign and date here in the presence of two adult witnesses, neither of whom is entitled to any part of your estate under a will or by operation of law, and neither of whom is your proxy.) I certify that the declarant voluntarily signed this living will in my presence and that the declarant is personally known to me. I am not named as a proxy by the living will, and to the best of my knowledge, I am not entitled to any part of the estate of the declarant under a will or by operation of law.
[seal]
Witness ..................................................................... Address .....................................................................
Witness ..................................................................... Address .....................................................................
Reminder: Keep the signed original with your personal papers. Give signed copies to your doctors, family, and proxy." History: 1989 c 3 s 4; 1991 c 148 s 6; 1992 c 535 s 1; 1995 c 211 s 1; 1998 c 254 art 1 s 107; 2005 c 10 art 4 s 2 Copyright © 2017 by the Revisor of Statutes, State of Minnesota. All Rights Reserved. 145B.04 MINNESOTA STATUTES 2017 4
Plan of Care: Patient will be kept comfortable for the evening and overnight. Family is staying the night for support. Plans will be made in the morning for where Sarah will go.
Pre-Simulation Questions: (3-5 full sentences detailing needs of this patient)
1. As patient is now DNR/DNI, what is your focus on her care? What is included in comfort cares?
2. What types of orders would you expect to receive from the provider?
3. How would the orders from the provider differ if the patient remained a full code?
Medications:
Current Medication List
Drug Classification, expected action, indication for use
Possible Adverse Effects
Medication or Food Interactions
Nursing Considerations
Client Education and Evaluation of Effectiveness
Alprazolam
Atropine
Haloperidol
Metoclopramide
Scopolamine
Current Medication List
Drug Classification, expected action, indication for use
Possible Adverse Effects
Medication or Food Interactions
Nursing Considerations
Client Education and Evaluation of Effectiveness
Omeprazole
Ferrous Sulfate
Docusate
Levothyroxine
Explanation / Answer
1 Many patients suffer unnecessarily when they do not recieve adequate attention for the symptoms accompanying serious illness.Careful evaluation of the patient should include not only the physical problems but also the psychosocial and spiritual dimensions dimensions of the patient and familys experience of serious illness.
2 Since the patient expressed some major problems such as dyspnea and altered with mental state,associated with a complicated medical history
3Advance directives atre written documents that allow the individual of sound mind to document preferences regarding end-of-life care that should be followed when the signer is terminally ill and unable to verbally communicate his/her wishes.The documents are generally completed in advance of serious illness,but may be completed after a diagnosis of serious illness if the signer is still of sound mind.The most common type the durable power of attorney for health care and living will.
4 CBC which is known as complete blood count helps in determining cell count for each cell type and the concentrations of various proteins and minerals.it helps in identifying certain diseases by looking into the increase and decrease in the number of cells.In this case since the patient has a history of anaemia differential will show a decrease in RBC
5 Basic metabolic panel is a blood test which consist of 7 0r 8 biochemical tests and is often ordered by health care providers.it consists of tests for Blood,Urea Nitrogen,creatinine,glucose,albumin,Bicarbonate,calcium,sodium,potassium and chloride.This test is performed to determine if the patient has any serious problems with blood filtration,blood sugar levels and electrolyte levels.
Drug classification,Expected Action /
Indication
Omiprazole -proton pump inhibitors
/Gastric acid pump inhibitor.
Short term treatment of active duodenal ulcer.First line therapy in the treatment of heart burn
Drug interactions
it potentially can increase the concentrations in blood of diazepam,Warfarin and Phenytoin by deccreasing the elimination of these drugs by the liver.
Nursing considerations
Ferrous sulphate-iron preparation.it elevates the serum iron concentration which then helps to form high or trapped in the reticuloendothelial cells for storage and eventual conversion to a usable form of iron.
indication-it helps in the prevention and treatment of anaemias and as a dietary supplement.
Nausea,muscle cramps,flushing and hypotension
Docusate-Laxative stool softener.it promotes incorporation of water into stool ,resulting in soft faecal mass.
For prevention of constipation.
throat irritation and mild cramps.
levothyroxin-thyroid hormones.
it increases the metabolic rate of body tissues and increases oxygen consumption.
Replacement therapy in hypothyroidism.
Used in treatment of thyrotoxicosis and myxedema
CNS tremors,headaches ,nervousness,allergic skin reactions,diarrhea,nausea,vomiting
Absorption reduced by some foods.Give atlreast 4 hrs apart from calcium carbonate and ferrous sulphate.
Drug classification,Expected Action /
Indication
Omiprazole -proton pump inhibitors
/Gastric acid pump inhibitor.
Short term treatment of active duodenal ulcer.First line therapy in the treatment of heart burn
Adverse effectsDiarrhea,nausea,fatigue,constipation ,flatulenceheadache,dizziness and cough.Drug interactions
it potentially can increase the concentrations in blood of diazepam,Warfarin and Phenytoin by deccreasing the elimination of these drugs by the liver.
Nursing considerations
- Advise patient not to open chew,crush the cappsules and ask them to swallow the whole capsule.
- Take the drug before meals
Ferrous sulphate-iron preparation.it elevates the serum iron concentration which then helps to form high or trapped in the reticuloendothelial cells for storage and eventual conversion to a usable form of iron.
indication-it helps in the prevention and treatment of anaemias and as a dietary supplement.
Nausea,muscle cramps,flushing and hypotension
- Advise the patient to take medicines as prescribed.
- Caution patient to make position changes.
- Inform patient that anginna attacks may occur 30 min after due reflex tachycardia
Docusate-Laxative stool softener.it promotes incorporation of water into stool ,resulting in soft faecal mass.
For prevention of constipation.
throat irritation and mild cramps.
Interactions with other patient drugs,OTC or herbal medicines.- Assess for abdominal distension
- presence of bowel sonds.
- Assess colour consistenc and amount of stool produced.
levothyroxin-thyroid hormones.
it increases the metabolic rate of body tissues and increases oxygen consumption.
Replacement therapy in hypothyroidism.
Used in treatment of thyrotoxicosis and myxedema
CNS tremors,headaches ,nervousness,allergic skin reactions,diarrhea,nausea,vomiting
Absorption reduced by some foods.Give atlreast 4 hrs apart from calcium carbonate and ferrous sulphate.
- Monitor thyroid function tests.
- check vital signs such as heart rate and BP