BSMCON NUR 3111P
PMH hepatic encephalopathy, GERD,
Hypertension
Cardizem CD 360mg po daily for hypertension. Calcium
channel blocker. Inhibits calcium ion influx across cardiac
and smooth muscle cells. Decreases myocardial
contractility and oxygen demand. Dilates coronary
arteries and arterioles. Lovenox 40mg injection daily for
anticoagulant therapy. Speeds up antithrombin III-
thrombin formation and disabes thrombin which stps the
conversion of fibrinogen to fibrin. Clopidogrel 75mg po
daily for antiplatelet therapy. Prevents the binding of
adenosine disphophate to its platelet receptor, ipending
ADP-mediated activation and subsequent platelet
aggregation and irreversibly modifies the platelet ADP
receptor. Metoprolol 40mg injection daily for high blood
pressure. Blocks beta 1 receptors; decreases cardiac
output and peripheral resistance and cardiac oxygen
consumption.
Priority Nursing Diagnosis (3 parts)
Chronic confusion related to chronic hepatic
encephalopathy as evidenced by A+O to person, and
rambling speech
Measurable outcome w/ timeframe:
The patient will become oriented to person place and
time every time I enter the room and will still be
oriented before I leave the room.
Nursing interventions you used with rationales:
1) Assess the degree of impairment the degree of
confusion will determine the amount of reorientation
and intervention the patient will need to evaluate
reality accurately.
2) Maintain consistency in the patients environment
and daily schedule consistency in placement of
furnishings promotes orientation and memory.
3) Provide safety measures to keep the patient safe.
The confused patient may lack appropriate insight
and judgment about environmental risks.
Evaluation:
The patient is still confused, but is kept safe and is
constantly reoriented.
Gulanick and Myers 8th Ed. Pages 47-50
Chief complaint altered mental status Asthma 1
atrial fibrillation, cirrhosis, debility
dysphagia CVA, chronic sinusitis,
hypoglycemia, monoclonal gammopathy,
The patient is having
DJD of lumbar and cervical spine as well
difficulty breathing
as hip, DDD of hip, obstructive sleep Asthma is an
with her COPD inflammatory process
whichapnea
will make the that causes Albuterol-Ipratropium 3mL nebulization
blood pump harder inflammation in the q4h as needed for SOB and respiratory
and faster trying to distress. Stimulates beta 2 receptors and
bronchioles making it inhibits vagally mediated reflexes resulting
compensate for lack difficult to breathe in bronchodilation. Albuterol 2 puffs q4h as
of oxygen just like with COPD needed for wheezing. Relaxes bronchial,
uterine, and vascular smooth muscle by
(MM, 78) stimulating beta 2 receptors.
COPD
Albuterol-Ipratropium 3mL nebulization
q4h as needed for SOB and respiratory distress.
Stimulates beta 2 receptors and inhibits vagally
COPD is an obstructive pulmonary mediated reflexes resulting in bronchodilation.
disease with progressive limitation in Tiotropium (Spiriva) inhalation of 1 capsule
airflow that is not fully reversible. daily for bronchodilation. Competitive,
Eventually the lungs lose their elasticity reversible inhibition of muscarinic receptors
and will be obstructed by mucus and leads to bronchodilation.
inflammation which causes gas exchange
to become difficult (Lewis 583). Patients daughter sitting with
patient ensures she eats and
is well taken care of. Patient
lives alone at home and was
found unconscious by
neighbor
Medications, diet, exercise,
frequent small high protein meals, WBC 7.3 normal RBC 3.76 low due to
COPD management inadequate production of RBCs HGB 11.4
low due to lower levels of iron HCT 34.1
low due to low hemoglobin PLT 384 normal
Na 141 normal K 3.8 normal Cl 107
normal CO2 27 normal BUN 5 low due to
diminished kidney function Creatinine 0.60
low because of diminished kidney function Ca
8.2 low due to low calcium intake
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Physical Assessment
This section must be completed by the stated due date/time and given to your instructor.

Document the assessment you completed.

Assessment Findings
Safety Allergies latex, adhesive, asa-acetampinophen-caff-potass, aspirin, avelox (Moxifloxacin), biaxin
(Clarithromycin), codeine indocin (indomethacin sodium), keflex (cephalexin), penicillin.
Medication checks. Schmid Fall Risk 4. Bed in lowest position. Non-slip socks. Bed alarm in
use.
Skin/Wounds Skin is clean, dry, and intact elastic. Bruising noted. Scars on abdomen due to multiple abdominal
surgeries. Braden score 15.
Respiratory Lung sounds are clear and symmetrical. Diminished on bilateral lower lobes. O2 Saturation 99%
on room air. RR 16 unlabored.
Cardiovascular HR 79 regular. No S3 or S4 sounds noted. No murmurs noted. Radial and pedal pulses +1
bilaterally. No edema noted. No JVD noted. Capillary refill <3 seconds. On telemetry. Atrial
fibrillation.
Gastrointestinal Normoactive bowel sounds. No masses or pain upon palpation. Last BM 10/6/1. Poor appetite. Ate
25% of breakfast.
Genitourinary Continent. Urine is yellow nonodorus. Foley is noted, but has since been removed. 900 mL in
foley. Patient has urinated since then in the toilet.
Neurological A&O to person. Rambling speech. Patient is confused. Gait is uneasy, but may ambulate with a
walker and assistance. PERRLA intact in both eyes. Patients face appears to be symmetrical
upon talking.
Musculoskeletal Gait requires assistance with walker and one person. Upper Extremity 3/5 equal bilaterally. Lower
Extremity strength 3/5 equal bilaterally. Patient is weak.
IV Lines Double lumen PICC line on right cephalic vein. 0.45% NS running at 50 mL/hr. Cardizem drip 5
Drains/Equipment mL/hr discontinued at 8:30 AM.

List two goals for the next practicum experience:

1. Become competent in neurological assessments and management of confused patients
2. Become more competent in preparing a patient for discharge
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Choose a program thread:

Communication and Collaboration
Caring and the Catholic Health Ministry
Servant Leadership and Global Health
Safe, Quality, Evidence-based Practice
Professionalism and Commitment to Lifelong Learning

Introduction

This week for practicum I encountered a patient who was alert and only oriented to person. She was able to talk and follow

commands, but she couldnt answer any questions that were asked of her. She was diagnosed with hepatic encephalopathy

which was part of the cause of her confusion.

Background

The patient entered the hospital unconscious. According to her chart, the neighbor found her and took her to the hospital.

She had been staying in the hospital for about a week and a half before I had the pleasure of meeting her. Upon doing my

pre-assessment, I discovered that she would probably be confused, but I wasnt really sure what to expect. When I entered

the room, I noticed that she was confused because when I had asked for her name and date of birth, she spelled out her

name for me. A similar experience I have had with a patient like this in the past would be my neighbors mother who was

diagnosed with Alzheimers disease. She was very confused, but really enjoyed attention and having something to do.

Learning that helped me with this patient because I was able to deter her attention from getting out of bed and onto

something else that would keep her attention. My beliefs as a nurse working on the situation were that she definitely needs

someone to advocate for her and take care of her because she is unable to do so herself. The situation made me very sad

because she was confused. She didnt know who was around her or what they were doing and that took away her autonomy

to make a choice in her healthcare.

Noticing

I initially noticed that the situation was under control. All safety precautions were utilized for this patient (ie: bed alarm, no-

slip socks, side rails up, etc) and she was kept pretty busy to keep her from hurting herself. As I spent more time with the

patient and family, I noticed that she was well cared for. Her daughter really cared for her and wanted to ensure that she was

well taken care of.

Interpreting

I thought that the entire situation was absolutely crazy. Its crazy to me that your liver has the ability to sway ones

consciousness and Im not entirely sure how it would be treated. The patient wasnt on any medications to help the altered

mental status so I would conclude that it wouldnt be treated all that well. I noticed that the patient was the most confused
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when she was in bed. When we got her up into the chair, she appeared to be much more alert and happy. An example of a

similar situation was when I was working at Louisa Health and Rehab Center working the evening shift as a tech. A patient

with dementia was sun downing and was very confused. He didnt exactly know where he was so orienting him to where he

was and the names of the staff was kind of challenging. Although the situations are caused by completely different things,

the patients were very similar through handling the confusion situation. I observed the electronic health record for any other

information I needed. I found that the patient had multiple things that may have altered her mental status such as COPD and

asthma, medications (side effects caused confusion), as well as the hepatic encephalopathy. My conclusions lead me to

believe that her confusion may be caused by a multitude of factors rather than just one thing.

Responding

After considering the situation, my goal for the patient was to keep her oriented and safe. She constantly tried to get out of

bed because she was confused. My nursing response was to continue orienting her to where she was and to keep

introducing those around her. I also ensured the patients safety by keeping a close eye on her at all times. Some stresses I

experienced were that the patient continued to try to get out of bed no matter the interventions I attempted and she was very

adamant about getting up so I kept trying to distract her and figure out why she wanted to get out of bed. She mostly just

wanted someone to hold her hand so I would hold her hand until she fell asleep or let go of it.

Reflection-on-Action and Clinical Learning

Three ways my nursing care skills expanded during this experience are that I gained a good knowledge on how to manage a

confused patient, I learned how to deter them from danger, and I learned a to perform a better neurological assessment.

Three things I would do differently are to know more about the different things that caused her confusion, to have better

ideas about how to distract a confused patient from doing harm to themselves, and finally to spend more time with the

patient or get a sitter to spend time with them to help keep them happy and away from harm. The only change in my values

as a nurse is that educating patients is very valuable. Teaching patients how to prevent certain things from happening to

them and how to take care of their bodies better is a huge factor in providing healthcare to patients.
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Lasater Clinical Judgment Rubric Scoring Sheet

Developed by Kathie Lasater, Ed.D.; Based on Tanners Integrative Model of Clinical Judgment (2006)

Student Name: Date/Time: Clinical Site:

Clinical Judgment Components Notes

Noticing:
Focused Observation: B D A E
Recognizing Deviations from Expected Patterns:
B D A E
Information Seeking: B D A E
Interpreting:
Prioritizing Data: B D A E

Making Sense of Data: B D A E

Responding:
Calm, Confident Manner: B D A E
Clear Communication: B D A E
Well-Planned Intervention/Flexibility: B D A E

Being Skillful: B D A E

Reflecting:
Evaluation/Self-Analysis: B D A E
Commitment to Improvement: B D A E
Summary Comments: