vSim H Williams Part 2 Clinical Packet Latest Update 2025

DESCRIBE DISEASE PROCESS AFFECTING PATIENT (Include Pathophysiology of Disease Process) Etiology and pathophysiology. The causes of major depression have not been established. Possible risk factors are genetic or environmental. Many studies have shown that children of a parent suffering from a major affective disorder have a rate of depression three to six times higher than that in the general population. Cognitive theories attribute the development of depression to feelings of hopelessness and helplessness secondary to an actual or perceived loss. Psychosocial theories point to factors such as disturbance in family dynamics or in the parent-child relationship, a family move, the death of a loved one, divorce, or abuse or maltreatment. Depression is a mood disturbance characterized by exaggerated feelings of sadness, despair, lowered self- esteem, loss of interest in former activities, and pessimistic thoughts. Depression is more than a state of mind; in any given 2-week period, almost 8% of Americans report symptoms of moderate or severe depression (Centers for Disease Control and Prevention [CDC], 2018). Depression is found in all races, ethnic groups, age groups, and socioeconomic levels. Women are affected twice as often as men. Depression can be so severe at times that an affected person contemplates, or succeeds at, committing suicide. Suicide falls in the top 10 leading causes of death in the United States; where the statistic falls in the top 10 depends on the age group (CDC, 2017). Many deaths supposedly caused by accidental overdoses, automobile accidents, and refusal of medical care may be viewed as hidden suicides even though they are not reported as such. Suicide attempts also are not included in the statistics. Although the highest rate of suicide is among the older population, suicide among teenagers is on the rise in this country. Children must be taught effective coping skills. There is great controversy over the terminally ill patient’s right to commit suicide. Some people believe that deliberately ending one’s life is a rational decision in certain circumstances, such as terminal illness, and defend the right to commit suicide. There is growing support for right-to-die legislation, which removes the criminal stigma from suicide. Most people who commit suicide in the hospital setting have received the diagnosis of an incurable or painful illness. It is important to evaluate terminally ill individuals and treat them for depression, as well as for their physical disorders, to ease their pain and enhance their quality of life. To help prevent suicide, recognize warning signs, and learn the kinds of actions that often can avert suicide attempts. Consider as warning signals verbal statements such as “I wish I were dead” or “You won’t see me coming back here again” and questions about specific methods of suicide. Actions such as giving away possessions, refusing medications, or neglecting hygiene are also possible warning signals. Many people have anxiety because of a moral conflict within themselves. Many suicidal individuals manage to leave that anxiety behind by making the decision to commit suicide. Major depression, or persistent depressive disorder, is defined as repeated, severe depressive episodes lasting more than 2 years (National Institute of Mental Health, 2018). Estimates are that up to 15% of people with major depressive disorder die from suicide. Dysthymic disorder is daily moderate depression that lasts more than 2 years. This disorder often ends up as a lifestyle in which the individual can function but not enjoy life. DIAGNOSTICS TESTS (Reason for Test and Results) No diagnostics but there are assessment tools that can help rate a patient’s level of depression. For example, The Geriatric Depression Scale and The Modified Caregiver Strain Index for the caregivers. PATIENT INFORMATION Henry Williams, 69-year-old African American retired Engineer. Only son died 10 years ago, Married. History of smoking, recurrent colds, bronchitis, asthma, COPD, HTN, Anxiety, Dyspnea, hyperlipidemia. Patient admitted for progressive shortness of breath, him and his wife live in a small apartment. Patient is waiting to be discharged to local rehabilitation center. He is generally tired and worries about his wife, who is experiencing frequent memory lapses. ANTICIPATED PHYSICAL FINDINGS ▪ No longer enjoying or caring about doing the things you used to. ▪ Feeling sad, down, hopeless, or cranky most of the day, almost every day. ▪ Losing or gaining weight without trying to do so. ▪ Sleeping too much or too little. ▪ Feeling tired or like you have no energy. ▪ Feeling guilty or like you are worth nothing. ▪ Forgetting things or feeling confused. ▪ Moving and speaking more slowly than usual. ▪ Acting restless or having trouble staying still. ANTICIPATED NURSING INTERVENTIONS Care at home: ▪ Ask your doctor what you need to do when you go home, make sure you ask questions if you do not understand what they say. ▪ Go to counseling or support groups as suggested by your doctor. ▪ Avoid beer, wine, and mixed drinks. Also avoid marijuana and illegal drugs. ▪ peak with trusted family and friends about your depression and how they can help. ▪ Exercise each day. Try to spend time outside each day. Sunshine may make you feel better. ▪ Have a regular sleep pattern and try to get 6 to 8 hours of sleep each night. ▪ Learn how to cope with stress. Guided imagery, yoga, tai chi, or deep breathing may help reduce your signs. Eating a healthy diet is important during this time. This means: ▪ Eat whole grain foods and foods high in fiber. ▪ Choose many different fruits and vegetables. Fresh or frozen is best. ▪ Eat fewer solid fats like butter or margarine. Eat less fatty or processed foods. ▪ Eat more low-fat or lean meats like chicken, fish, or turkey. Eat less red meat. ▪ Avoid caffeine. Try not to drink soda, coffee, tea, or energy drinks. To prevent depression, you can: ▪ Exercise each day. ▪ Try to spend time outside each day. Sunshine can make you feel better. ▪ Have a regular sleep pattern where you get 6 to 8 hours of sleep each night. ▪ Learn how to cope with stress. Guided imagery, yoga, tai chi, or deep breathing may help relieve your signs. ▪ Learn about depression and its signs. Then, you can get help early. ▪ Join a support group. Learn how others are living well with depression. VSIM ISBAR ACTIVITY Student Worksheet INTRODUCTION Milagros Ballesteros, LPN, Hospital Your name, position (RN), unit you are working on SITUATION Henry Williams is a 69-year-old male who was admitted five days ago with progressive shortness of breath. Waiting on discharge to rehab center Patient’s name, age, specific reason for visit BACKGROUND Diagnosis of possible depression. Patient waiting on discharge to the local rehabilitation center later this afternoon. He has been weak and has progressed slowly with his pulmonary rehabilitation. He is generally tired and worries about his wife, who is experiencing frequent memory lapses. Discharge patient to rehabilitation facility for follow up with self-care and pulmonary rehabilitation Discharge Medications: Fluticasone propionate 250 mcg nebulized every 12 hours Albuterol 2 puffs as needed for acute onset of shortness of breath Rosuvastatin calcium 20 mg PO every evening Lisinopril 12.5 mg PO daily Metoprolol tartrate 50 mg PO daily Acetylsalicylic acid 81 mg PO daily Montelukast 10 mg PO every evening Prednisone 40 mg for 2 more days, then 20 mg for 5 days, then 10 mg for 5 days and follow up in the clinic for further Patient’s primary diagnosis, date of admission, current orders for patient ASSESSMENT Vitals are stable: HR 83, RR 15, O2 93%, BP 128/84, 98.6 F. All physical assessments are within normal findings. Current pertinent assessment data using head-to-toe approach, pertinent diagnostics, vital signs. RECOMMENDATION Any orders or recommendations you may have for this patient Assessment of his independence in activities of daily living, and the results are in the chart. Mr. Williams will need education at discharge about his medication, about care he will receive at the long-term care facility, and about insurance coverage. The medication reconciliation documentation should also be done. The rehabilitation center will need to be called with a report on Henry and his plan of care. Henry plans to go there for about a week of therapy, then go into assisted living with his wife. NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: Fluticasone propionate CLASSIFICATION: Corticosteroids PROTOTYPE: Hydrocortisone CONTRAINDICATIONS: hypersensitivity to drug/class/components, severe hypersensitivity to milk protein, status asthmaticus, asthma (acute), bronchospasm (acute), avoid abrupt withdrawal, caution in pediatric or adolescent patients, caution if mod-severe hepatic impairment, caution if recent long-term systemic corticosteroid treatment, caution if immunosuppressed, caution if active infection, caution if TB infection, active or latent, caution if measles or varicella exposure, caution if osteoporosis, caution if osteoporosis risk, caution if cataracts, caution if glaucoma, caution if glaucoma risk, caution if ocular HSV ADVERSE EFFECTS: Serious Reactions: hypersensitivity reaction, anaphylaxis, bronchospasm, eosinophilia, Churg-Strauss syndrome, adrenal suppression, (long-term use), hypercorticism (long-term use), glaucoma (long-term use), cataracts (long-term use), osteoporosis (long-term use), growth suppression (long-term use in peds patients) Common Reactions: nasopharyngitis, headache, bronchitis, influenza, RI, sinusitis, oropharyngeal pain, pharyngitis, back pain, dysphonia, candidiasis (oral), rhinitis, throat irritation, abdominal pain, cough BLACK BOX WARNINGS: WARNINGS: Flonase (fluticasone) can cause slowing of growth in children, especially if the medication is used for a long period of time. Use the lowest dose of Flonase (fluticasone) for the shortest period of time for children. Do not use this for more than 2 months out of the year unless a doctor tells you this is okay SAFE DOSE OR DOSE RANGE, SAFE ROUTE Route: PO-INHALED Dosage: DPI: 100 mcg per blister, 200 mcg per blister asthma, maintenance treatment: [1 puff inhaled qd] Start: varies per disease severity and current asthma treatment, may increase dose after 2wk; Max: 1 puff/24h up to 200 mcg/24h; Info: taper to lowest, effective dose PURPOSE FOR TAKING THIS MEDICATION Fluticasone inhalation is a steroid that is used to prevent asthma attacks in adults and children. Fluticasone inhalation is sometimes used together with steroid medicine taken by mouth. Flovent brands of fluticasone inhalation may be used in children as young as 4 years old. Arnuity Ellipta should not be used in children younger than 5 years old, and ArmonAir should not be used in anyone younger than 12 years old. PATIENT EDUCATION WHILE TAKING THIS MEDICATION PATIENT EDUCATION WORKSHEET ▪ Fluticasone inhalation is a steroid that is used to prevent asthma attacks in adults and children. Fluticasone inhalation is sometimes used together with steroid medicine taken by mouth. Follow all directions on your prescription label and read all medication guides or instruction sheets. Use the medicine exactly as directed. Do not use the medicine more often than prescribed. ▪ Fluticasone inhalation is not a rescue medicine for asthma attacks. Use only fast-acting inhalation medicine for an attack. Seek medical attention if your breathing problems get worse quickly, or if you think your asthma medications are not working as well. ▪ Flovent is a liquid form of fluticasone used with an inhaler device. This device creates a spray that you inhale through your mouth and into your lungs. ▪ Flovent Diskus, ArmonAir, and Arnuity Ellipta are powder forms of fluticasone that come with a special inhaler device preloaded with blister packs containing measured doses of fluticasone. The device opens and loads a blister of fluticasone each time you use the inhaler. ▪ Read and carefully follow any Instructions for Use provided with your medicine. Ask your doctor or pharmacist if you do not understand these instructions. ▪ Do not allow a young child to use this medicine without help from an adult. ▪ To prevent a yeast infection, rinse your mouth with water (do not swallow) after using this medicine. Pay close attention to your dental hygiene. Fluticasone can cause cavities or tooth discoloration. ▪ Your dose needs may change if you have surgery, are ill, are under stress, or have recently had an asthma attack. Do not change your medication dose or stop using fluticasone without your doctor's advice. ▪ You should not stop using fluticasone inhalation suddenly or your asthma could get worse. ▪ If you stop taking any steroid medicine, you may need to stop gradually. Follow your doctor's instructions. ▪ In case of emergency, wear or carry medical identification to let others know you may need an oral steroid in an emergency. ▪ Your doctor will need to check your progress on a regular basis. Your vision may also need to be checked at regular intervals. ▪ Call your doctor if your symptoms do not improve after 2 weeks of treatment, or if symptoms get worse. If you use a peak flow meter at home, call your doctor if your numbers are lower than normal. ▪ Store at room temperature away from moisture, light, and extreme heat or cold. ▪ Store ArmonAir in the foil pouch and use the medicine right away after opening. Discard the empty pouch in a place children and pets cannot reach. Store in a dry place. ▪ Store the powder forms in the unopened foil pouch or tray until ready to use. Throw away any unused medicine when the inhalations counter on your inhaler device shows "0." Get your prescription refilled before you run out of medicine completely. ▪ Store the Flovent HFA canister with the mouthpiece down. Keep the canister away from open flame or high heat, such as in a car on a hot day. The canister may explode if it gets too hot. Do not puncture or burn an empty inhaler canister. ▪ If you miss a dose skip the missed dose and use your next dose at the regular time. Do not use two doses at one time. ▪ If you use Arnuity Ellipta, do not use more than 1 inhalation per day. PATIENT EDUCATION WORKSHEET ▪ Avoid being near people who are sick or have infections. Call your doctor for preventive treatment if you are exposed to chickenpox or measles. These conditions can be serious or even fatal in people who are using steroid medicine. NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: Albuterol Sulfate CLASSIFICATION: Bronchodilator PROTOTYPE: Beta 2 agonist CONTRAINDICATIONS: Contraindicated in patients hypersensitive to drug or its ingredients. Use cautiously in patients with CV disorders (including coronary insufficiency and HTN), hyperthyroidism, or diabetes mellitus and in those who are unusually responsive to adrenergics Use extended-release tablets cautiously in patients with GI narrowing. ADVERSE EFFECTS: CNS: tremor, nervousness, headache, hyperactivity, insomnia, dizziness, weakness, CNS stimulation, malaise. CV: tachycardia, palpitations, HTN, chest pain, lymphadenopathy, edema. EENT: conjunctivitis, otitis media, dry and irritated nose and throat (with inhaled form), nasal congestion, epistaxis, hoarseness, pharyngitis, rhinitis. GI: nausea, vomiting, heartburn, anorexia, altered taste, increased appetite. GU: UTI. Metabolic: hypokalemia. Musculoskeletal: muscle cramps, back pain. Respiratory: bronchospasm, cough, wheezing, dyspnea, bronchitis, increased sputum. Other: hypersensitivity reactions, flulike syndrome, cold symptoms. BLACK BOX WARNINGS: 1. Paradoxical Bronchospasm: Inhaled albuterol sulfate can produce paradoxical bronchospasm that may be life threatening. If paradoxical bronchospasm occurs, Albuterol sulfate inhalation aerosol should be discontinued immediately, and alternative therapy instituted. It should be recognized that paradoxical bronchospasm, when associated with inhaled formulations, frequently occurs with the first use of a new canister. 2. Deterioration of Asthma: Asthma may deteriorate acutely over a period of hours or chronically over several days or longer. If the patient needs more doses of Albuterol sulfate inhalation aerosol than usual, this may be a marker of destabilization of asthma and requires re-evaluation of the patient and treatment regimen, giving special consideration to the possible need for anti-inflammatory treatment, e.g., corticosteroids. 3. Use of Anti-inflammatory Agents: The use of beta-adrenergic-agonist bronchodilators alone may not be adequate to control asthma in many patients. Early consideration should be given to adding anti- inflammatory agents, e.g., corticosteroids, to the therapeutic regimen. 4. Cardiovascular Effects: Albuterol sulfate inhalation aerosol, like other beta-adrenergic agonists, can produce clinically significant cardiovascular effects in some patients as measured by pulse rate, blood pressure, and/or symptoms. Although such effects are uncommon after administration of Albuterol sulfate inhalation aerosol at recommended doses, if they occur, the drug may need to be discontinued. In addition, beta-agonists have been reported to produce ECG changes, such as flattening of the T wave, prolongation of the QTc interval, and ST segment depression. The clinical significance of these findings is unknown. Therefore, Albuterol sulfate inhalation aerosol, like all sympathomimetic amines, should be used with caution in patients with cardiovascular disorders, especially coronary insufficiency, cardiac arrhythmias, and hypertension. 5. Do Not Exceed Recommended Dose: Fatalities have been reported in association with excessive use of inhaled sympathomimetic drugs in patients with asthma. The exact cause of death is unknown, but cardiac arrest following an unexpected development of a severe acute asthmatic crisis and subsequent hypoxia is suspected. 6. Immediate Hypersensitivity Reactions: Immediate hypersensitivity reactions may occur after administration of albuterol sulfate, as demonstrated by rare cases of urticaria, angioedema, rash, bronchospasm, anaphylaxis, and oropharyngeal edema. SAFE DOSE OR DOSE RANGE, SAFE ROUTE Route: PO-Inhalation, tab, syrup Dosage: Tablets (extended-release): Adults and children older than age 12: 4 to 8 mg PO every 12 hours. Maximum, 32 mg daily. Tablets: Adults and children older than age 12: 2 to 4 mg PO t.i.d. or q.i.d. Maximum, 32 mg daily. Solution for inhalation Adults and children age 12 and older: 2.5 mg by nebulizer, given over 5 to 15 minutes, t.i.d. or q.i.d. To prepare solution, use 0.5 mL of 0.5% solution diluted with 2.5 mL of NSS. Or, use 3 mL of 0.083% solution. Syrup: Adults and children older than age 14: 2 to 4 mg PO t.i.d. or q.i.d. Maximum, 32 mg daily. Inhalation aerosol: Adults and children age 4 and older: 1 to 2 inhalations every 4 to 6 hours as needed. Regular use for maintenance therapy to control asthma symptoms isn’t recommended. PURPOSE FOR TAKING THIS MEDICATION To prevent or treat bronchospasm in patients with reversible obstructive airway disease PATIENT EDUCATION WHILE TAKING THIS MEDICATION PATIENT EDUCATION WORKSHEET ▪ Warn patient about risk of paradoxical bronchospasm and advise patient to stop drug immediately if it occurs. ▪ Teach patient to perform oral inhalation correctly. ▪ If prescriber orders more than 1 inhalation, tell patient to wait at least 2 minutes before repeating procedure. ▪ Tell patient that use of a spacer device with appropriate inhaler may improve drug delivery to lungs. ▪ If patient is also using a corticosteroid inhaler, instruct patient to use the bronchodilator first and then to wait about 5 minutes before using the corticosteroid. ▪ Tell patient to remove canister and wash aerosol inhaler with warm, soapy water at least once a week. ▪ Warn patient not to wash or place any part of powder inhaler in water. If mouthpiece needs cleaning, advise patient to gently wipe it with dry cloth or tissue. ▪ Advise patient not to use more than prescribed and not to increase dose or frequency without consulting physician. Fatalities have been reported from excessive use. ▪ Instruct patient to report worsening symptoms. ▪ Advise patient not to chew or crush extended-release tablets or mix them with food. ▪ If you use an albuterol inhaler, ask your pharmacist or doctor to check that you are using it correctly. You will need to prime your inhaler before you first use it, or if you haven't used it for a long time, by test spraying (three for ProAir HFA: four times for Ventolin HFA or Proventil HFA) into the air. Always test spray Ventolin HFA if you have dropped it. Follow the instructions provided with the inhaler. ▪ To use the inhaler, exhale slowly and place the mouthpiece of the inhaler well into the mouth with the lips closed around it. As you push down on the inhaler, inhale slowly and deeply through the mouth. Hold your breath for as long as possible, withdraw the mouthpiece, and exhale slowly. Allow 1 minute between doses if you are prescribed two doses at once. ▪ Most inhalation devices require regular cleaning or else they will clog. Follow the instructions provided on how to clean your device and mouthpiece. Discard canister after the labeled number of actuations used. ▪ Store your device at room temperature away from heat, cold, open flames, and moisture. Do not puncture or burn an empty canister. ▪ Before using your inhaler, shake it well. Avoid spraying into the eyes. Rinse eyes with water if this happens by accident. ▪ Albuterol extended-release tablets should be swallowed whole and not chewed or crushed. ▪ Albuterol relieves breathlessness but does not reduce inflammation. Needing to use albuterol more frequently than usual may be a sign that your asthma is destabilizing, and you should seek immediate medical advice for a re-evaluation of your treatment regimen and the possible need for anti- inflammatory treatment (such as corticosteroids) to heal the airways. Deterioration of asthma can occur quite quickly over several hours, or it may take days or weeks. ▪ Albuterol alone is usually not enough to achieve good asthma control in most adults and children with asthma. Corticosteroids (such as budesonide [Pulmicort] or fluticasone [Flovent]) are often also needed. ▪ Always keep albuterol on hand at all times and refill your prescription before you run out completely. Keep using all other medications as prescribed by your doctor. ▪ Seek emergency help if you have signs of an allergic reaction (breathing difficulties, facial swelling, hives), chest pain or fast heart rate, pain or burning when you urinate, signs of high blood sugar (increased thirst, increased urination, hunger, dry mouth), or signs of low potassium (such as leg cramps, irregular heartbeat). NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE MEDICATION: Rosuvastatin CLASSIFICATION: HMG CoA reductase inhibitors PROTOTYPE: Lipophilic Statins PATIENT EDUCATION WORKSHEET CONTRAINDICATIONS: Hypersensitivity to drug/class/components, pregnancy (non-high-risk pts), myopathy, unexplained elevated LFTs, active hepatic disease, caution if alcohol abuse, caution in pts 65 year old and older, caution in female pts of reproductive potential, caution if renal impairment, caution if hepatic disease history, caution if diabetes mellitus, caution if hypothyroidism. ADVERSE EFFECTS: Serious Reactions: myopathy, immune-mediated necrotizing myopathy, rhabdomyolysis, acute renal failure, hepatotoxicity, pancreatitis hypersensitivity reaction, anaphylaxis, angioedema, lupus erythematosus, polymyalgia rheumatica, dermatomyositis, vasculitis, thrombocytopenia, leukopenia, hemolytic anemia, photosensitivity, toxic epidermal necrolysis, erythema multiforme, Stevens-Johnson syndrome, interstitial lung disease. BLACK BOX WARNINGS: Possible adverse effects on cognitive performance including memory loss, amnesia, and confusion. SAFE DOSE OR DOSE RANGE, SAFE ROUTE Route: PO Dosage: Extended-release Tabs: 20 mg, 40 mg, 60 mg PURPOSE FOR TAKING THIS MEDICATION Lovastatin is used together with diet to lower blood levels of "bad" cholesterol (low-density lipoprotein, or LDL), to increase levels of "good" cholesterol (high-density lipoprotein, or HDL), and to lower triglycerides (a type of fat in the blood). Lovastatin is used to lower the risk of stroke, heart attack, and other heart complications in adults with diabetes, coronary heart disease, or other risk factors. PATIENT EDUCATION WHILE TAKING THIS MEDICATION ▪ Follow all directions on your prescription label and read all medication guides or instruction sheets. Your doctor may occasionally change your dose. Use the medicine exactly as directed. ▪ Swallow the tablet whole and do not crush, chew, or break it. ▪ It may take up to 4 weeks before your cholesterol levels improve, and you may need frequent blood tests. Even if you have no symptoms, tests can help your doctor determine if this medicine is effective. ▪ You may need to stop using lovastatin for a short time if you have surgery or a medical emergency. Do not stop taking this medicine unless your doctor tells you to. ▪ Lovastatin is only part of a complete treatment program that may also include diet, exercise, and weight control. Follow your doctor's instructions very closely. ▪ Store at room temperature away from moisture, heat, and light. ▪ You should not take lovastatin if you have active liver disease, or if you are pregnant or breastfeeding. ▪ Tell your doctor about all your current medicines and any you start or stop using. Many drugs can interact, and some drugs should not be used together. ▪ Do not take two doses at one time. ▪ Avoid eating foods high in fat or cholesterol, or lovastatin will not be as effective. ▪ Avoid drinking alcohol. It can raise triglyceride levels and may increase your risk of liver damage. ▪ Grapefruit may interact with lovastatin and lead to unwanted side effects. Avoid the use of grapefruit products. ▪ Stop taking this medicine and tell your doctor at once if you become pregnant. NAME OF MEDICATION, CLASSIFICATION AND INCLUDE PROTOTYPE