Question

DRUGS CARD FOR

Hydrochloroquine
Remdesivir
Zithromax
Apresoline
Infliximab
Morphine

careplan for GI bleeding and Covid 19 patients

Answer 1

Ans) Care plan for GI bleeding:

Nursing assessment:

Determine the patient’s health history for signs that can be associated with a risk for bleeding such as liver disease, inflammatory bowel disease, or peptic ulcer disease. Early identification of possible risks for bleeding provides a foundation for implementing appropriate preventive measures.

Monitor patient’s vital signs, especially BP and HR. Look for signs of orthostatic hypotension. Hypotension and tachycardia are initial compensatory mechanisms usually noted with bleeding. Orthostasis (a drip of 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP when changing from supine to sitting position) indicates reduced circulating fluids.

Evaluate the patient’s use of any medications that can affect hemostasis (e.g, anticoagulants, salicylates, NSAIDs, or cancer chemotherapy). Drugs that interfere with clotting mechanisms or platelet activity increase risk for bleeding. Salicylates and other NSAIDs inhibit cyclooxygenase 1 (COX)-1, an enzyme that promotes platelet aggregation. Warfarin, an oral anticoagulant, inhibits the synthesis of vitamin K in the liver, thus reducing levels of several subsequent clotting factors. Heparin, a parenteral anticoagulant, inhibits the action of thrombin and prevents formation of a fibrin clot. many drugs used to treat cancer suppress bone marrow function and therefore the production of platelets.

Review laboratory results for coagulation status as appropriate: platelet count, prothrombin time/international normalized ratio (PT/INR), activated partial thromboplastin time (aPTT), fibrinogen, bleeding time, fibrin degradation products, vitamin K, activated coagulation time (ACT). The blood clotting cascade is an integral system requiring intrinsic and extrinsic factors. Derangements in any factors can affect clotting ability. These laboratory tests provide important information about the patient’s coagulation status and bleeding potential. The specific laboratory values to be monitored will depend on the patient’s specific clinical condition. For patient’s receiving anticoagulants, increased levels of PT/INR and aPTT above therapeutic values are associated with increased risk for bleeding. Reduced platelet counts may develop in patients receiving heparin therapy.

Check stool (guaiac) and urine (Hemastix) for occult blood. These tests are used to distinguish bleeding from the gastrointestinal or urinary tracts that may not be visible.

Assess skin and mucous membranes for signs of petechiae, bruising, hematoma formation, or oozing of blood. Patient with reduced platelet counts or impaired clotting factor activity may experience bleeding into tissues that is out of proportion to the injury. Prolonged oozing of blood from surgical incisions or areas of skin trauma is associated with coagulation abnormalities.

Monitor hematocrit (Hct) and hemoglobin (Hgb). When bleeding is not visible, decreased Hgb and Hct levels may be an early indicator of bleeding.

Goals/Outcome:

- Patient takes measures to prevent bleeding and recognizes signs of bleeding that need to be reported immediately to a health care professional.

Patient does not experience bleeding as evidenced by normal blood pressure, stable hematocrit and hemoglobin levels and desired ranges for coagulation profiles.

Nursing Interventions

The following are the therapeutic nursing interventions for Risk for Bleeding:

Nursing Intervention & Rationales:

Educate the at-risk patient about precautionary measures to prevent tissue trauma or disruption of the normal clotting mechanisms. Information about precautionary measures lessens the risk for bleeding.

Use a soft-bristled toothbrush and nonabrasive toothpaste. Avoid the use of toothpicks and dental floss.

This method providing oral hygiene reduces trauma to oral mucous membranes and the risk for bleeding from the gums.

Avoid rectal suppositories, thermometers, enemas, vaginal douches, and tampons.

These invasive devices or medications may cause trauma to the mucous membranes that line the rectum or vagina.

Limit straining with bowel movements, forceful nose blowing, coughing, or sneezing.

These activities may cause trauma to the mucosal linings in the rectum, nasal passages, or upper airways.

Be careful when using sharp objects like scissors and knives. Use an electric razor for shaving (not razor blades).

The patient needs to avoid situations that may cause tissue trauma and increase the risk for bleeding.

When laboratory values are abnormal, administer blood products as prescribed. Blood product transfusions replace blood clotting factors; RBCs increase oxygen-carrying capacity; FFP replaces clotting factors and inhibitors; platelets and cryoprecipitate provide proteins for coagulations.

Educate the patient and family members about signs of bleeding that need to be reported to a health care provider. Early evaluation and treatment of bleeding by a health care provider reduce the risk for complications from blood loss.

For bleeding linked with excessive anticoagulant use, give appropriate antidotes as prescribed. Protamine sulfate reverses the effect of heparin. Vitamin K will counteract the action of warfarin.

Monitor for skin necrosis, changes in blue or purple mottling of feet that blanches with pressure or fades when legs are elevated. Patient on anticoagulant therapy remains at risk of developing emboli.

Let the patient use normal saline nasal sprays and emollient lip balms. These treatments reduce drying and cracking of mucous membranes and therefore reduce the risk of bleeding.

Explain to a sexually active patient the use water-soluble lubricants during intercourse. Lubricants are used to reduce friction and tissue trauma that increase the risk for bleeding.

Teach the patient about measures to reduce constipation such as increased fluid intake and dietary fiber. Hard and dry feces may cause trauma to the mucous membranes of the colon and rectum. Increasing fluid intake and dietary fiber soften the fecal mass for easier defecation.

Inform the patient to check the color and consistency of stools. Bright red blood in the stools is an indicator of lower gastrointestinal bleeding. Stool that has a dark greenish-black color and a tarry consistency is linked with upper gastrointestinal bleeding.

Tell the female patient to inform the health care provider when there is an increase in menstrual bleeding as indicated by an increase in the number of sanitary pads used. Alterations in coagulation may lead to increased blood loss with regular menstruation.

Tell the patient to observe skin and mucous membranes for oozing of blood. Oozing of blood is often an early sign of coagulation abnormalities that increase the risk of bleeding.

Educate the patient about over-the-counter drugs and avoid products that contain aspirin or NSAIDs such as ibuprofen and naproxen. These drugs not only decrease normal platelet aggregation but also decrease the integrity of gastric mucosa through inhibition of cyclooxygenase (COX)-1 inhibitor and therefore increase the risk for gastrointestinal bleeding.

Educate the patient and family members about limiting the use of herbal remedies that are linked with an increased risk for bleeding like dongquai, feverfew, ginger, ginkgo biloba, and chamomile. Most herbal preparations interfere with platelet aggregation through inhibition of serotonin release from the platelet. Other herbs increase the effect of antiplatelet and anticoagulant medications, thus increasing the risk for bleeding.

Provide psychological and emotional support to the patient. This helps in patient’s assurance and calming.

Tell the family members to be active in decision-making about the treatment of the patient at risk for bleeding. Active participation encourages fuller understanding of the rationale and compliance with the treatment.

Keep in touch with blood transfusion center. This is to assure the availability of blood when needed.

Care plan for COVID patient:

Nursing Leadership Concerns

Nursing literature on the SARS epidemic identified challenges faced by nursing leadership during a period of patient surge related to infectious disease.10 Five stages experienced by nurse leaders were identified as facing shock and chaos, sourcing for reliable sources to clarify myths, developing and adjusting nursing care, supporting nurses and their clients, and rewarding nurses.

We recommend that nurse leaders collaborate with hospital administrators to develop consistent and regularly scheduled methods of updating staff on operating conditions, safety concerns, and other issues related to surge capacity.
Nurse leaders should be prepared to assist staff in managing internal conflict between personal and professional responsibilities.
We recommend that nurse leaders identify resources for assistance in mitigating internal conflicts among staff working under surge conditions, such as social workers and mental health personnel.
We recommend that even in times of surge, nurse leaders provide meaningful recognition to staff engaged in patient care efforts. This recognition promotes a healthy work environment and reinforces staff resilience.
Nurse Safety and Resilience

We suggest that facilities implement proactive strategies to prevent staff attrition due to fatigue or illness. These include the provision of mental health support, ensuring safe utilization of personal protective equipment to prevent staff infection, and maintaining a healthy work environment. Perceived organizational support had an impact on predicting burnout in Canadian nursing staff during the SARS crisis.

We recommend implementation of a safety officer role to monitor PPE and staff exposure risk as part of a total staff safety model. This individual could be an Emergency Medical Technician or Nursing Technician familiar with PPE, or another identified individual who is trained in PPE utilization. The safety officer could provide just-in-time training for those not comfortable with donning and doffing of PPE, and, intermittently, audit PPE utilization.
We recommend that each care team designate a team safety officer to ensure team members are taking routinely scheduled breaks for hydration, rest, toileting, and refreshments. Staff should also be assessed for skin breakdown related to extended time periods in PPE.
Provide staff with resources to plan with their family in advance of reporting to their first shift.
Promote a team culture, particularly if staff are staying on-site during their off time. This may include team meals, team exercise sessions, or other bonding activities.
Provide access to mental health support for staff feeling overwhelmed or concerned. SARS team nurses in Taiwan demonstrated worry about infecting family and colleagues. Utilization of video communication with family members reduced nurse worry.
We recommend that hospital administration maintain visibility with impacted patient care areas to provide support. Mechanisms should be in place for addressing staff concerns about psychosocial issues and working conditions. Meaningful recognition of staff providing support during the surge effort should be provided at regular intervals.