iHuman patient Amka Oxendine
Prework
1. What are your primary concerns for this patient and what assessments and interventions would be associated with
... [Show More] your concerns and why? Denies SOB, vomiting, palpitations, chest pain, or unusual bleeding. Patient feels “overwhelmed and alittle stressed.” I feel so alone” I have not been out with friends.”
My primary concern with this patient would be to check if she has any difficulty breathing at this time, or palpitations, or chest pain. Any unusual bleeding would be one of my priority as well. Next I would do a neuro check to make sure perrla is noted. I would also assess for anorexia, nausea, vomiting, malaise, excessive sweating and confusion which could be signs of liver failure.
Interventions:
• Assess time of ingestion and reason why it was ingested (time medication is ingested is very important when deciding the right treatment)
• Complete drug history to make sure of any other medication that could have been ingested as well
• Assess patient for malnutrition and alcohol use (increase risk of hepatotoxicity)
• In case the patient is in distress restore airways by oxygen therapy
• Give fluid as prescribed
• Use appropriate antidote as prescribed such as N-acetylcysteine
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., & Bucher, L. (2017). Medical surgical nursing: Assessment and management of clinical problems (10th ed.). Mosby.
2. What medications do you anticipate the health care provider would prescribe while the patient is in the hospital and why?
a. Acetylcysteine to stop the effect of the overdose. It prevents some of problems caused by an overdose.
b. Cimetidine to slow the effect of acetaminophen
c. Emetics
d. Activated charcoal to help soak up the acetaminophen that is still in her stomach.
e. 0.9% saline
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., & Bucher, L. (2017). Medical surgical nursing: Assessment and management of clinical problems (10th ed.). Mosby.
Vallerand, A. H., Sanoski, C. A., & Quiring, C. (2019). Davis's drug guide for nurses (16th ed.). F.A. Davis.
3. What medications do you anticipate the health care provider prescribing for the patient’s discharge and why?
a. Proton pump inhibitor in case of any stomach ulcers
b. Anti-emetic
c. Anti depressant
• Acetylcysteine is an antidote. If your body has already digested the acetaminophen, it stops the effect of the overdose. It also prevents some of the problems caused by an overdose.
• Cimetidine or another stomach medicine may be given to slow the effects of acetaminophen.
• Emetics are medicines that cause you to vomit.
• Activated charcoal helps to soak up the acetaminophen that is still in your stomach. Activated charcoal will make you vomit.
• Monitoring of patients receiving intravenous NAC generally involves: 1) 1-2 hours before the 16 hour infusion will be finished, an acetaminophen level, AST, ALT, and INR should be measured, 2) if no acetaminophen is detected and the AST, ALT, and INR are normal, the infusion can be finished and treatment is complete, and 3) if there is measurable acetaminophen (and with this the possibility of further formation of NAPQI) or the AST, ALT, or INR are elevated (evidence of nursece4less.com nursece4less.com nursece4less.com nursece4less.com 32 hepatotoxicity), the patient may need more NAC.5 This issue will be discussed later in this section
Nurses Notes
Situation: Amka is a 19 year old Caucasian female who was transferred from the emergency department.
Background: Amka ingested 15 extra strength of acetaminophen pills a 8pm after a phone call from her boyfriend. After 4 hours she was brought to the emergency department by the EMS. She has known allergy and is a full code.
Assessment: The patient is awake, alert, visibly exhausted. She reports nausea, abdominal pain, malaise, and report feeling hat and clammy. At this time she denies vomiting, shortness of breath, chest pain and palpitations. Acetaminophen level is decreasing toward normal levels.
Height/weight: 127.6 lbs
Temp: 37.6c
Pulse: 66
RR: 12
SpO2: 98%
BP: 116/74
Pain: 0/10
Patient IV line is patent, no phlebitis, infiltration, extravasation or hematoma noted, device is well secured, no client concerns.
Skin, hair, nails: skin pale warm and diaphoretic. Multiple scarred areas of various lengths on medial thighs, bilateral. Nails without ridging, pitting, or peeling. Skin turgor appropriate for patient’s age. Capillary refill less than three seconds.
HEENT
Head: normocephalic, atraumatic, no deformities, facial feature symmetric, temporal arteries non-tender to palpation, frontal and maxillary sinuses non tender.
Eyelids: no ptosis, erythema, or swelling, conjunctivae is pin with no discharge, sclerae is white, orbital area has no edema, redness, tenderness or lesions noted.
Ears: No deformities or discharge noted.
Nose: no discharge or polyps, no edema or tenderness over the frontal or maxillary sinuses.
Neck: full range of motion, trachea is midline and freely mobile. Thyroid firm, an acceptable size for patient gender and age. No nodules palpated.
Mouth: no hoarseness, clear mucosa, tonsils without exudate, tongue pink in color, symmetrical, no swelling or ulcerations.
Respiratory: chest is symmetrical, excursion with respiration is symmetrical and there are no retractions or use of accessory muscles. No distention, scars, masses, or rashes.
Cardiac: regular rhythm, 2+, no murmurs or bruits.
GI: abdomen is flat and symmetric with no scars, deformities, striae or lesions, no pain, tenderness, masses, or pulsations, no guarding or rebound tenderness. No tympany or shifting dullness.
Extremities: no deformity, there is no cyanosis clubbing or edema. Erythemic rash noted at IV site.
GI: no masses or tenderness, no urethral discharge.
Musculoskeletal: full range of motion. Strength is 5/5 bilaterally.
Neuro: cranial nerves II-XII intact. Patient is alert, attentive, and oriented. Though slow to respond. Speech is clear and fluent with stunted repetition, comprehension and naming.
Recommendation: suicide precaution until the patient is seen by a psychiatric. [Show Less]