Comprehensive Assessment nausea by benbenzhou


Comprehensive Assessment nausea

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									                 Comprehensive Assessment   1

Comprehensive Assessment

 Maranda McCray-Dixon

    Dr. Chris Nelson

      Nursing 470L

    October 12, 2006
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                                Comprehensive Assessment

       D.B. is a 9 year old Biracial (black father, white mother) male who resides at a

Pediatric Long Term care facility because of the long term diagnosis of a traumatic brain

injury. D.B. is totally dependent on the staff for all ADLs. A typical day for D.B. would

be waking up around 7:00am for morning care, morning feedings and meds through a

PEG tube, and being dressed for school. He attends Heritage, a special education school

from 9-2:30 pm where he responds to environmental stimuli and learns in a

nontraditional way. After D.B arrives home at about 3:00 pm, he is taken out of his

wheelchair and his school clothes, put in more comfortable clothes and he is and placed

in bed watching cartoons. He usually sleeps until bath time which is every other day, or

until 6:00pm feeds and meds. After this he usually lays in bed listening to cartoons until

he falls asleep. The goals and expectations for the future are not to rehabilitate D.B. but

to habilitate him. With his brain injury being so devastating the goal is to keep him at his

current level of function. The admitting diagnosis for D.B. was Intentional Traumatic

Brain injury with Intracranial Hemorrhages.

       Health History and History of present illness was obtained by the nurses and the

charts because he could not be a historian. Prior to admission to the facility, he was

essentially healthy. There are no long standing diseases from prior to the injury save for a

Tonsil and Adenoid removal. D.B. started out as a typical child with a normal

developmental childhood, but at the age of 8 he was subjected to extreme physical abuse

from a mother’s boyfriend. The sequele of the injuries is that he is unable to

communicate effectively (grunts and moans), partially blind, unambulatory, suffers from
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seizure disorders, Renal Kidney Hydronephrosis, Resolved Decompression Craniotomy,

Scoliosis, Severe Kyphosis, Encephalopathy, Incontinence, and Malnutrition.

       The physical examination reveals a rectal Temperature of 99.0, Pulse 80 right

radial, regular rhythm, Blood Pressure 106/70 right arm supine, Respirations 19, Chest

expansion symmetric. Though D.B. is unresponsive it is assumed that his pain scale is

low because there are no visible signs of pain such as grimacing or crying. Assessment of

the lymph nodes revealed no large swollen or tender masses. Pupils are equal round and

react to light. Inspection of the nose reveals no large or tender masses, there is a septum

present. Inspection of the oral mucosa yields some hyperplasia of the gums especially by

the molars. There are still some teeth that have not yet erupted. Inspection of the external

ear revealed intact skin with no pain or lesions. The patients skin is smooth with no

breaks, there is no erythema, edema, or decubitus sores to note. D.B. does have a

gastrostomy tube, which the incision is healed well around the tube. When the hair is

separated the scars from the injury can be seen. Nail beds are pink with a normal

capillary refill. During examination of the musculoskeletal system kyphosis and extreme

scoliosis is noted. D.B. also has hand splints for both of his hands to keep them from

balling up and excoriating himself. While listening to his lungs they were equal

bilaterally with symmetric rising. When palpating the stomach it felt firm and upon

auscultation there were infrequent high pitched sounds. The genetalia is appropriate size

and development for his age. D.B.’s legs are usually flexed in the fetal position when
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placed in his bed. There are no lesions or breaks in skin noted on the lower extremities of

the body. There were no recent diagnostic tests to note in the chart.

       D.B.’s current medication includes:

       Carbamazepine (Anticonvulsant) 200 mg/11ml via Gtube three times a day

       Action: Decreases synaptic transmission in the CNS by affecting Na channels in


       Side effects: ataxia, drowsiness, fatigue, psychosis, vertigo, blurred vision,

       corneal opacities, pneumonitis, CHF, hyper or hypo tension, syncope, hepatitis,

       urinary retention, photosensitivity, rashes, urticaria, SIADH Agranulocytosis,

       Aplastic anemia, Thrombocytopenia, eosinophilia, leucopenia, chills fever and


       Clonazepam (Benzodiazepine) 0.25 mg via Gtube twice a day

       Action: Anticonvulsant effects may be due to presynaptic inhibition.

       Side effects: Abnormal eye movements, aphonia, choreiform movements, coma,

       diplopia, dysarthria, dysdiadochokinesis, "glassy-eyed" appearance, headache,

       hemiparesis, hypotonia, nystagmus, respiratory depression, slurred speech,

       tremor, vertigo, Confusion, depression, amnesia, hallucinations, hysteria,

       increased libido, insomnia, psychosis, suicidal attempt (the behavior effects are

       more likely to occur in patients with a history of psychiatric disturbances). Chest
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congestion, rhinorrhea, shortness of breath, hypersecretion in upper respiratory

passages. Palpitations. Hair loss, hirsutism, skin rash, ankle and facial edema.

Anorexia, coated tongue, constipation.diarrhea, dry mouth, encopresis, gastritis,

hepatomegaly, increased appetite, nausea, sore gums. Dysuria, enuresis, nocturia,

urinary retention. Muscle weakness, pains. Dehydration, general deterioration,

fever, lymphadenopathy, weight loss or gain. Anemia, leukopenia,

thrombocytopenia, eosinophilia. Transient elevations of serum transaminases and

alkaline phosphatase.

Clonidine Patch (antiHypertension)0.2mg topical once a week

Action: Stimulates alpha adrenergic receptors in the CNS; Which results in the

decreased sympathetic outflow inhibiting cardio acceleration and

vasoconstriction centers.

Side Effects: drowsiness depression dizziness, nervousness, nightmares,

bradycardia, hypotension, palpitations, dry mouth constipation, vomiting, nausea,

impotence rash, sweating, Na retention, weight gain.

Dantrolene (antispasticity)10mg/2ml via Gtube three times a day

Actions: acts directly on skeletal muscle causeing relaxation by decreasing

calcium release from sarcoplasmic reticulum in muscle cells.

Side effects: Drowsiness, muscle weakness, hepatotoxicity, diarrhea.
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Diazepam (anticonvulsant) 2mg via gtube three times a day

Action: Depresses the CNS, produces skeletal muscle relaxation by inhibiting

spinal polysynaptic afferent pathways.

Side Effects: dizziness, drowsiness, lethargy, blurred vision, respiratory

depression, constipation, diarrhea, nausea, rashes, physical dependence.

Lansoprazole suspension (Gerd) 30mg/10ml once a day

Action: Binds to an enzyme in the presence4 of acidic gastric pH, Preventing the f

inal transportof H+ ions into the gastric lumen

Side Effects: dizziness, headache, diarrhea

Methylphenidate (Tx of ADHD, symptomatic Tx of Narcolepsy)5mg via Gtube

once a day

Action: Produces CNS and respiratory stimulation with weak sympathomimetic

activity, increases attention span in ADHD.

Side effects: hyperactivity, insomnia, restlessness, tremor, dizziness, headache,

irritability, hypertension, palpitations, tachycardia, anorexia.

Polyethelyne Glycol Powder (laxative)8.5mg via Gtube in 8oz h2o once a day

Action: In a solution acts as an osmotic agent drawing water into the lumen of the

GI tract.

Side effect: abdominal bloating, cramping, flatulence, nausea.
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Rantidine (H2 antagonist) 30mg/2ml via Gtube twice a day

Action: Inhibits action of histamine at the H2 receptor site located primarily in the

Gastric Parental Cells resulting in inhibition of gastric acid secretion.

Reuteri Primadophilus (herbal supplement)5ml oral twice a day prior to feeds

Action: recolonizes the stomach with normal bacteria in order to help stool to


Side effects: none listed

Acetaminophen Liquid (pain reliever/fever reducer) 380/11.8ml via Gtube as


Action: Inhibits the synthesis of prostaglandins that may serve as mediators of

pain and fever, primarily in the CNS

Side Effects: hepatic failure, hepatoxicity, renal failure, rash, uticaria

Albuterol (Bronchodilator) inhalant as needed every four hours

Actions: Binds to beta 2 adrenergic receptors in airway smooth muscle and leads

to vasodilation.

Side effects: nervousness, restlessness, tremor, headache, insomnia, chest pain,

palpitations, angina, arrythmias, hypertension, nausea, vomiting, hyperglycemia,

hypokalemia, and tremor.
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       Bisacodyl Suppository (laxative) every third day as needed

       Action: Stimulates Peristalsis, produces fluid accumulation in colon.

       Side Effects:abdominal cramps, nausea, diarrhea, rectal burning, hypokalemia,

       muscle weakness, protein losing enteropathy tetany.

       Guaifenesen (expectorant) 75mg/3.75ml via Gtube every four hours

       Action: reduces viscosity of tenacious secretions by increasing respiratory tract


       Side effects: dizziness, nausea, headache, diarrhea,stomach pain, nausea, rashes,


       Ibuprofen Liquid (nonopiod analgesic)250mg/12.5ml via Gtube

       Action: Inhibits prostaglandin synthesis

       Side Effects: headache, constipation, dyspepsia, nausea, vomiting

       Nutritional Assessment

       According to the determine tool D.B. is at a high nutritional health risk. D.B. diet

consists of 240 mls Kindercal Junior formula administered by G tube three times a day.

This diet is adhered to by the facility workers and the special school workers during the

day. D.B’s height and weight is 53” and 85 pounds. Some of the problems related to

dietary intake is D.B.s gingival hyperplasia and under erupted teeth.
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          Teaching Plan/ Nursing Care Plan

          No family is present to teach, D.B. is cognitively incapable to learn from a

teaching plan, and the nurses already have specific plans for D.B. The primary nursing

care plan is to turn and position D.B. frequently to prevent skin breakdown.

          Most of the psychosocial Dimension does not apply to D.B. because he is unable

to show cognition to his surroundings aside from pain he rarely shows emotion. It may be

noted that he is somewhat attached to his nurses and he does enjoy the stimulation of


          Based on my assessment of the client and your analysis of the data I feel D.B. is

in a state of adaptive equilibrium.

          Prioritized list of client’s current and potential problems

          1) Risk for impaired nutrition

          2) Risk for skin breakdown

          Client’s strengths

          1) D.B. is well care for by skilled nurses

          2) D.B. is seen by a team of other healthcare providers including MDs,

             Dietitians, Dentists, and Physical Therapy.

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