Adverse reactions anticoagulants antithrombotics 60

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Adverse Reactions anticoagulants antithrombotics 60 mg/0.6mL q12 hr dizziness, headache, insomnia. CV: edema. GI: constipation, ↑ liver enzymes, nausea, vomiting. GU: urinary retention. Derm: alopecia, ecchymoses, pruritus, rash, urticaria. Hemat: BLEEDING, anemia , eosinophilia, thrombocytopenia. Local: erythema at injection site, hematoma, irritation, pain. MS: osteoporosis. Misc: fever Why is patient receiving this Route and Frequency Nursing Considerations and 7
med? (Can list related diagnosis, symptom, or need) 8
Routine Findings Patient Variations/Abnormal Skin – Patient’s skin is even and consistent with ethnicity. Skin is elastic and there are no signs of dehydration. Moderate non-pitting edema of the right fingers, fingers warm, capillary refill <2 seconds. Skin warm and dry. Head and neck – Patient’s head and scalp are normocephalic, there are no lesions or infestations. Facial expression is appropriate and facial features are symmetric. There are no tattoos or piercings. The lymph nodes are not palpable. Neck motion is smooth and controlled and has full ROM PERRLA Respiratory Lung expansion is symmetrical and there are no masses or tenderness noted. Respirations are regular and even and chest expands symmetrically with each inspiration. There are no masses or tenderness noted. Lungs are clear, no adventitious sounds heard. Lungs clear. Cardiovascular- no mumurs, S1&S2 are heard. No jugular vein distention. pts chest is symmetric. Carotid pulse is palpable. Pedal pulses 2+. Radial pulse 2+ on left. Abdomen – Skin is even and pink throughout. Contour is flat. Abdomen is symmetric. Umbilical is midline. No pulsations present. Skin is intact. Bowels are active in all 4 quadrants. abdomen soft and non-tender with hypoactive BS in all four quadrants. Bowel continence? Last BM? Bowel Plan? Neurological – Pt A&O x4 to person, place, time, date, and situation. A&O to person, place, and situation. Musculoskeletal- Color is consistent with ethnicity. Contour of all joints are intact and equally bilateral. No crepitus, lesions, edema, masses, or deformities Radial joint not intact 9
Genitourinary - no lesions, rashes, wounds, tattoos, piercings, discharge. Urinary is consistent. Urinary continence? Toileting plan? Voided 200 mL clear amber urine. Nursing Diagnosis #1: Acute pain Related to (RT): Fracture of right radius As evident by (AEB): Pain 9/10 in right wrist and hand, dull and throbbing. Planning/Desired Outcome(s): D.H. will report her pain is controlled and tolerable by discharge. Implementation/Nursing intervention(s): Rationale Evaluation/Patient Response Assess if client is able to provides a self-report of pain intensity, and if so, assess pain intensity level using valid and reliable self-report pain tool, such as the 0-10 numerical pain rating scale (Ackley et al, Pg. 640).

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