Nursing Care Plan

N4810 Clinical Paperwork Rev 11/6/13

CSU, STANISLAUS B.S.N. CLINICAL PLAN OF CARE

Patient Data Student Ikneet Kandola Date of Care 02/2015 Room Number 45B Code Status: DNR

Pt. Initials AA Gender F Age 72 Height 167.6cm Weight 70kg BMI 25.18 Spirituality Catholic Ethnicity Caucasian Admitting Diagnosis: severe sepsis and ALOC r/t UTI Vital Signs: Temp 97.2 HR 98 RR 20 B/P 118/54 O2 Sat 98 Pain Scale & Scale Type 0 on 0-10 scale History related to this admission recurrent CDIFF. Pt was in the hospital 1/28/15 Past Medical History Type 2 DM 2009, COPD/emphysema 2013, asthma, coronary athersosclerosis/CAD, HTN, hypercholesteremia, peripheral neuropathy, Herpes zoster 2005, viral hepatitis A 1995, open wound of knee, leg, & ankle 7/26/10, closed fracture of shaft of Rt humerus, recurrent bladder infections, A-Fib 9/14/13, PVD, diabetic retinopathy 2013, hypoglycemia 2013, carotid artery stenosis 4/7/2013, syncope & collapse 4/6/2013, atopic dermatitis 10/31/12, acute bronchitis 3/8/12, chest pain pleuritic 3/28/12, ARF 2/8/15, mental status alt 2/8/15 Admit Date 02/08/2015 POD N/A Surgical History & Date Total abd hysterectomy 1968, cholecystectomy 1965, appendectomy 1966, thoracotomy excision of Bullae date unknown, PTCA 2000, bilat leg artery surgery-blockage-bilat stent legs unknown date, cataract extraction 9/17/13 MD(s) Tesfaye, B hospitalist; Fung MD

Diet All clear fluids changed to controlled carb diabetic diet Activity Bed rest; ambulates w/ 2 person assist Foley Yes Feeding Tube & Rate N/A Advance Directive: Yes No X Drains/ Tubes N/A Isolation Contact: CDIF VS Freq routine Glucose Monitoring ACHS TID DVT Prophylaxis SCD’s, Eliquis Vascular Access: peripheral PCA/Epidural N/A Telemetry & Rhythm Continuous monitoring; A-Fib IV Site: Rt. wrist 22g IV Solution & Rate: Cardizem 125mg in D5W 125mL: 10mL/hr Safety Considerations fall risk precautions Restraints N/A IV Site: Rt. Forearm 20g IV Solution & Rate: NaCl 0.9% 20mL/hr Labs for day of clinical: CBC, BMP, ECG Dressing Changes & Frequency N/A Scheduled Procedures 2/11/15@ 1540 CT Abd Pelvis; WBC body scan: 2/12/15 Procedures done this admission EKG, Abd pelvis contrast, chest contrast, brain CT, WBC Body scan Oxygen 2L NC Respiratory Treatment: Duoneb Vent Settings: BiPAP 8 bpm Advanced Hemodynamic Monitoring & Values N/A IV Drips Medications Dosage & Rate: Cardizem 125mg in D5W 125mL: 10mL/hr NaCl 0.9% 20mL/hr; Notes on Pathophysiology: sepsis: life threatening complication of an infection. SIRS. Body has severe response to bacteria. A-fib: quivering, irregular heartbeat that can lead to blood clots, stroke, HF, and other heart related complications.

N4810 Clinical Paperwork Rev 11/6/13

CALIFORNIA STATE UNIVERSITY, STANISLAUS

MEDICATION WORKSHEET Allergies: fish: swelling & itching, shellfish is ok; Naproxen: swelling & itching; Opioid analgesics: codeine: 1 tab keeps her awake 24 hrs; sulfa

antibiotics: hives; plastic tape: rash, paper tape is ok.

N4810 Clinical Paperwork Rev 11/6/13

Medication

Generic & Trade Name

Dose, Route, Frequency

Mechanism of Action

Classification

Patient-Specific Rationale

Nursing Considerations

(Assessment implications, side effects, reasons

to hold med, administration rate, etc…)

SCHEDULED MEDS

Apixaban (Eliquis)

5mg PO BID

Apixaban is a selective inhibitor of

FXa. It does not require

antithrombin III for antithrombotic

activity. Apixaban inhibits free and

clot-bound FXa, and

prothrombinase activity. Apixaban

has no direct effect on platelet

aggregation, but indirectly inhibits

platelet aggregation induced by

thrombin. By inhibiting FXa,

apixaban decreases thrombin

generation and thrombus

development.

Anticoagulant

Pt is on this med because she

has A-fib which increases her

risk for stroke and clots.

Monitor PT, INR, PTT for coagulation

studies. Assess for signs of bleeding: RBC,

skin, etc.

s/e: bleeding, bruising, sedation

Carvedilol (Coreg)

6.25mg PO BID w/ breakfast

and dinner

Blocks stimulation of beta 1 and

beta 2 adrenergic receptor sites.

Anti-hypertensives; betablockers

Pt has HTN Assess BP, HR before and after

administration. Hold if SBP < 110 or HR

<60. Take with food to minimize

orthostatic hypotension.

s/e: bradycardia, anxiety, depression, HF,

insomnia, memory loss, decreased libido

Cyanocobalamin (Vitamin

B-12)

100mcg PO Daily

Important for metabolism.

Essential for normal growth, cell

reproduction, maturation of RBCs,

nucleoprotein synthesis,

maintenance of nervous system

(myelin synthesis), and believed to

be involved in protein and

carbohydrate metabolism. Also

acts as coenzyme in various

biologic reactions. Helps with

formation of RBCs, and

Pt has chronic anemia. Monitor RBC, Hgb, Hct before and during

therapy. Therapeutic response is within 48

hours. Instruct pt about proper diet to aid

with vit b12 deficiency.

s/e: loss of balance, numbness or tingling of

arms & legs, weakness

N4810 Clinical Paperwork Rev 11/6/13

maintenance of CNS.

Water-soluble vitamin

Diltiazem (Cardizem)

125mg in D5W 125mL

5-15 mg/hr IV drip titrate

Current dose: 10mg/hr

Inhibits transport of calcium unto

myocardial and vascular smooth

muscle cells, resulting in inhibition

of excitation-contraction coupling

and subsequent contraction. TE:

Systemic vasodilation resulting in

↓ frequency and severity of attacks

of angina. ↓ of ventricular rate in

atrial fibrillation or flutter

Antianginals, antiarrhythmics,

antihypertensives; calcium channel

blocker

Pt has A-Fib Monitor BP, pulse, I&O, Rash, and ECG

continuously.

Assess HR & BP before and after

administration. Hold if SBP <110 or

HR<60. Call provider if SBP <90. notify

for signs of irregular heart beats, dyspnea,

swelling of hands and feet, pronounced

dizziness; avoid large amounts of grapefruit

juice.

Admin instructions: starting dose 5mg/hr.

Titrate by 5mg/hr. Titration interval: every

30 min. Goal: maintain HR b/w 60-100

bpm. Max dose: 15mg/hr.

s/e: peripheral edema, bradycardia,

hypotension, dizziness, arrhythmias,

vomiting, Stevens-Johnson Syndrome

Insulin glargine (Lantus)

Inj pen 10 units Subq Daily

Lowers blood glucose by:

stimulating glucose uptake in

skeletal muscle & fat, inhibiting

hepatic glucose production.

Antidiabetic hormone

Pt has Type 2 DM Monitor glucose levels. Instruct how to use

and administer with pen for discharge:

prime with 2 units, dial to 10 units, press the

pen down till you hear the click and inject,

hold for as many secs as the units being

given: 10 units= hold for 10 secs

Assess for symptoms of hypoglycemia:

anxiety, restlessness, tingling in hands, feet,

lips, or tongue, chills, cold sweats,

confusion, cool, pale skin, difficulty in

concentration, drowsiness, nightmares or

trouble sleeping, excessive hunger,

headache, irritability, nausea, nervousness,

tachycardia, tremor, weakness, unsteady

gait. & assess symptoms of hyperglycemia

(5 p’s).

Must be checked by two nurses before

administration.

s/e: Hypoglycemia, erythema,

N4810 Clinical Paperwork Rev 11/6/13

lipodystrophy, pruritis, swelling,

anaphylaxis

Drug interaction w/ beta blockers can cause

S&S of hypoglycemia.

Insulin lispro human

(humalog)

Inj pen 1-18 units Subq TID

w/ meals

Dose depends on blood

glucose monitoring (ACHS

TID), and the sliding scale:

70-150: 0 units

151-200: 3 units

201-250: 6 units

251-300: 9 units

301-350: 12 units

351-400: 15units

>400: give 18 units and call

MD. Draw serum blood

glucose.

Lowers blood glucose by:

stimulating glucose uptake in

skeletal muscle & fat, inhibiting

hepatic glucose production.

Antidiabetic hormone

Pt has Type 2 DM Monitor glucose levels. Instruct how to use

and administer with pen for discharge:

prime with 2 units, dial to 10 units, press the

pen down till you hear the click and inject,

hold for as many secs as the units being

given: 10 units= hold for 10 secs

Assess for symptoms of hypoglycemia:

anxiety, restlessness, tingling in hands, feet,

lips, or tongue, chills, cold sweats,

confusion, cool, pale skin, difficulty in

concentration, drowsiness, nightmares or

trouble sleeping, excessive hunger,

headache, irritability, nausea, nervousness,

tachycardia, tremor, weakness, unsteady

gait. & assess symptoms of hyperglycemia

(5 p’s).

Must be checked by two nurses before

administration.

s/e: Hypoglycemia, erythema,

lipodystrophy, pruritis, swelling,

anaphylaxis

Drug interaction w/ beta blockers can cause

S&S of hypoglycemia.

Insulin lispro human

(Humalog)

Inj pen 1-5 units Subq qHS

Dose depends on blood

glucose monitoring (ACHS

TID), and the sliding scale:

200-250: 1 unit

251-300: 2 units

301-350: 3 units

351-400: 4 units

Lowers blood glucose by:

stimulating glucose uptake in

skeletal muscle & fat, inhibiting

hepatic glucose production.

Antidiabetic hormone

Pt has Type 2 DM Monitor glucose levels. Instruct how to use

and administer with pen for discharge:

prime with 2 units, dial to 10 units, press the

pen down till you hear the click and inject,

hold for as many secs as the units being

given: 10 units= hold for 10 secs

Assess for symptoms of hypoglycemia:

anxiety, restlessness, tingling in hands, feet,

lips, or tongue, chills, cold sweats,

confusion, cool, pale skin, difficulty in

concentration, drowsiness, nightmares or

trouble sleeping, excessive hunger,

headache, irritability, nausea, nervousness,

N4810 Clinical Paperwork Rev 11/6/13

>400: 5 units; call MD and

draw serum blood glucose.

tachycardia, tremor, weakness, unsteady

gait. & assess symptoms of hyperglycemia

(5 p’s).

Must be checked by two nurses before

administration.

s/e: Hypoglycemia, erythema,

lipodystrophy, pruritis, swelling,

anaphylaxis

Drug interaction w/ beta blockers can cause

S&S of hypoglycemia.

Ipratropium/Albuterol

(Duoneb)

0.5mg/2.5mg/3mL

3mL PO INH q4h by RT

Decreased intracellular calcium

relaxes smooth muscle airways.

Bronchodilates to control and

prevent reversible airway

obstruction caused by asthma or

COPD. Inhalation provides quick

relief for acute bronchospasm.

The combination of these meds,

Duoneb, is expected to maximize

the response to treatment in

patients with COPD by reducing

bronchospasm through two

distinctly different mechanisms:

sympathomimetic (albuterol

sulfate) and

anticholinergic/parasympatholytiw/

(ipratropium bromide).

Simultaneous administration of

both an anticholinergic and a β2-

sympathomimetic is designed to

produce greater bronchodilation

effects than when either drug is

utilized alone.

β2-adrenergic bronchodilator;

anticholinergic bronchodilator

Pt has COPD. Assess for lungs sounds, pulse, BP. Note

color/character of sputum. Monitor

pulmonary function. Observe for

paradoxical bronchospasm (wheezing),

HOLD medication and contact physician.

May cause transient decrease in serum

potassium concentrations.

Use first if using other inhalers & allow 5

min in between.

Instruct pt to rinse mouth after use, instruct

pt how to use device.

For nebulizer, compressed air or oxygen

flow should be 6-10 L per min.

Use medication as directed.

s/e: Nervousness, restlessness, tremor,

chest pain, palpitations

Occurs more frequently in children than

adults.

Use cautiously with pts with cardiac

disease, hypertension, diabetes.

Menthol/zinc oxide

(Calmoseptine Ointment)

Soothes and helps promote healing

of impaired skin. Relieves skin

irritations.

Pt is experiencing skin

irritation on the buttocks.

Assess skin integrity and improvement.

Instruct pt how to apply:

N4810 Clinical Paperwork Rev 11/6/13

1 application topical to

buttocks BID

Analgesic, antiseptic, antipruritic,

skin protectant

Gently wash the affected area. Pat

dry or allow to air dry.

Apply a thin layer of Calmoseptine

ointment to the affected area as

directed by your doctor or the

package labeling. Rub in gently.

Wash your hands right away after

using Calmoseptine ointment, unless

your hands are part of the treated

area.

s/e: Severe allergic reactions (rash; hives;

itching; difficulty breathing; tightness in the

chest; swelling of the mouth, face, lips, or

tongue).

Metronidazole (Flagyl)

500 mg in 0.79% NaCl

100mL(premix)

500mg IV q8h

Disrupts DNA and protein

synthesis in susceptible organisms.

Bactericidal action.

Anti-infectives, antiprotozoals;

antiulcer agents

Pt has UTI Assess pt for infection: VS, sputum, urine,

stool, WBC before and during therapy.

Obtain specimens for culture and sensitivity

testing.

Avoid alcohol and other alcohol-containing

preparations (e.g., elixirs, cough syrups,

tonics). Avoid driving or other activities

requiring alertness because med causes

dizziness.

s/e: Seizures, dizziness, headache, abd pain,

anorexia, nausea.

Simvastatin (Zocor)

40mg PO qHS

Inhibits HMG-CoA reductase,

which is responsible for catalyzing

an early step in the synthesis of

cholesterol.

Lipid-lowering agents; HMG-CoA

reductase inhibitors.

Pt has hypercholesteremia Evaluate serum cholesterol and triglyceride

levels. If pt develops muscle tenderness

during therapy, monitor CK levels. Pt

should notify MD if unexplained muscle

pain, tenderness, or weakness occurs. Avoid

>200mL/day of grapefruit juice.

s/e: Abdominal cramps, constipation,

diarrhea, flatus, heartburn, rhabdomyolysis,

rashes.

N4810 Clinical Paperwork Rev 11/6/13

Vancomycin (Vancocin)

50mg/mL PO Sln

250mg PO q6h

Inhibits proper cell wall synthesis

in gram-positive bacteria. For use

in colitis.

Glycopeptide antibiotic

Pt has an infection. Monitor WBC, VS, cultures. Instruct pt to

finish course of antibiotic therapy.

s/e: bladder pain, bloody or cloudy urine,

decreased urine, irregular heartbeat

PRN MEDICATIONS

Acetaminophen (Tylenol)

650mg PO q4h prn

Inhibits the synthesis of

prostaglandins that may serve as

mediators of pain and fever,

primarily in the CNS. Has no

significant anti-inflammatory

properties or GI toxicity.

Antipyretics, nonopiod analgesics

Pt is on this med for fever r/t

infection

Assess pain scale.

Chronic excessive use of >4 g/day (2 g in

chronic alcoholics) may lead to

hepatotoxicity, renal or cardiac damage,

avoid alcohol to decrease liver damage.

Dose limit is 3 g. Overdose can result in

severe toxicity.

s/e: headache, fatigue, insomnia,

dyspnea,hypertension/hypotension,

HEPATOTOXICITY (↑ DOSES),

constipation, ↑ liver enzymes, nausea,

vomiting, hypokalemia, renal failure (high

doses/chronic use) rash, urticaria.

Docusate Sodium (Colace)

100mg PO BID prn

Water in stool to make softer fecal

matter, promote electrolyte and

water into the colon. Softens stool

for passage.

Laxatives; stool softeners

Pt is on this med for potential

constipation.

Assess for bowel sounds and bowel

function; color, consistency and amount of

stool produced. Assess for abd distention.

Teach pt only to use for short term, long

term will cause electrolyte imbalance and

dependence. Try to get pt to use other forms

of bowel regulation (increase diet, fluid

intake, mobility). Pt with cardiac disease

avoid straining during bowel movement.

Not to use when abdominal pain, nausea,

vomiting, or fever. Do not take within 2 hr

of other laxative

s/e: Throat irritation, mild cramps, diarrhea,

rash

N4810 Clinical Paperwork Rev 11/6/13

Hydrocodone/acetaminophen

(Norco 5)

5mg/325mg PO q4h prn pain

Binds to opiate receptors in the

CNS. Alters the perception of and

response to painful stimuli. CNS

depression. Decrease in severity of

moderate pain. Suppression of

cough reflex.

Allergy, cold, and cough remedies

(antitussive), opiod analgesics;

opioid agonists/nonopioid

analgesic combinations

Pt is on this med for pain (pt

has hx of back pain that

comes and goes)

Assessment

Assess BP, P, RR before and periodically

during administration. RR <10 breaths per

min, assess level of sedation.

Assess bowel function routinely. Increase

fluid and bulk to prevent constipation.

Assess pain: type, location, intensity of

pain, prior to and 1 hr following

administration.

Assess cough: assess cough and lung sound

when using as an antitussive.

Implementation

HIGH ALERT: Accidental overdosage of

opioid analgesics has resulted in fatalities.

Before administering, clarify all ambiguous

orders, have second practitioner

independently check original order and dose

calculations.

Medications should be discontinued

gradually after long term use to prevent

withdrawal symptoms.

Advise pt to take medication as directed.

Liver damage may result from prolonged

use.

May cause drowsiness or dizziness.

Advise pt to change positions slowly to

minimize orthostatic hypotension.

s/e: CNS: confusion, dizziness, sedation.

CV: hypotension, bradycardia. GI:

constipation, dyspepsia, nausea

Levalbuterol (Xopenex)

1.25mg/0.5mL

Neb Sln 1.25mg INH q4h

prn

Binds to beta 2-adrenergic

receptors on airway smooth

muscle. This leads to the activation

of adenylate cyclase and to an

increase in the intracellular

concentration of cyclic-3', 5'-

adenosine monophosphate (cyclic

AMP). This increase in cyclic

Pt is on this med for

bronchitis r/t her COPD and

asthma.

Assess for lungs sounds, pulse, BP. Note

color/character of sputum. Monitor

pulmonary function. Observe for

paradoxical bronchospasm (wheezing),

HOLD medication and contact physician.

Use albuterol first if using other inhalers &

allow 5 min in between, Rinse mouth after

use, instruct pt how to use device.

N4810 Clinical Paperwork Rev 11/6/13

AMP leads to the activation of

protein kinase A, which inhibits

the phosphorylation of myosin and

lowers intracellular ionic calcium

concentrations, resulting in

relaxation of the smooth muscles

of all airways.

Bronchodilator; Beta2-adrenergic

agonist

Dilute with normal saline to 3mL

s/e: Paradoxical bronchospasm, chest pain,

arrhythmia

Magnesium Sulfate 2g in

water for inj 50mL IVPB

(premix)

2g IV prn Mg between 1.5-

1.9

Magnesium Sulfate 3g in D5

100mL IVPB

3g IV prn Mg between 1.2-

1.4

Magnesium Sulfate 4g in

sterile water 100mL IVPB

(premix)

4g IV prn Mg between 0.9-

1.1

Essential for the activity of many

enzymes. Important role in

neurotransmission and muscle

excitability.

Mineral and electrolyte

replacements/supplements

Pt has hx of Magnesium

deficiency. This will replace

magnesium needed for many

organ functions.

Monitor Magnesium levels before and

during therapy. Use with caution with

eliquis.

Administration instructions: use scale to

determine dose.

s/e: Confusion, dizziness or

lightheadedness, fast, slow, or irregular

heartbeat, low blood pressure, muscle

weakness

Ondansetron (Zofran)

2mg/mL Inj

4mg IV q6h prn

Blocks the effects of serotonin at

5-HT3 receptor sites located in

vagal nerve terminals & the

chemoreceptor trigger zone in the

CNS.

Antiemetics; 5-HT3 antagonists

Pt is on this med for potential

N/V

Assess pt for nausea, vomiting, abdominal

distention, & bowel sounds prior to & after

admin. Assess pt for extra pyramidal

effects: involuntary movements, facial

grimacing, rigidity, shuffling walk,

trembling of hands.

Instruct pt to take Ondansetron as directed.

Advise pt to notify STAT of extra

pyramidal effects.

IV push at 1 to 4 mg over 2 to 5 mins.

s/e: Headache, constipation, diarrhea,

abdominal pain, dry mouth, extra pyramidal

N4810 Clinical Paperwork Rev 11/6/13

effects, fatigue, dizziness, increase liver

enzymes.

N4810 Clinical Paperwork Rev 11/6/13

LABORATORY DATA: newest to oldest

LABS Normal Range (Fill in Hospital Norms)

RESULT 1 (date & time)

2/12 0630

RESULT 2 (date & time)

2/11 0614

RESULT 3 (date & time)

2/10 0352

Reason for abnormal lab

values r/t diagnosis &

nursing implications

CBC

WBC 4-11 16 trend ↓ 19.9 15.2 Above NR. Increased levels indicate infection. Pt dx UTI. Pt is on antibiotics thus the values are going back towards normal. Floor staff must maintain proper hand hygiene by “gelling in & out.” Sterile procedures and all invasive procedures must be done with the proper and necessary precautions to reduce the risk and spread of infection. Monitor WBC and VS (fever).

RBC 3.9-5.4 3.04 trend ↓ 3.17 2.98 Below NR. Monitor RBC

and for signs of nausea, light-headedness, weakness. Pt has ARF and chronic anemia and is on Vit B-12 replacement. Continue to monitor RBC for improvement.

Hemoglobin 11.7-15.5 8.7 trend ↓ 9.1 8.6 Below NR. Decrease in RBC will result in a decrease in HGB. Critical low levels may lead to angina, heart attack, CHF, stroke. Continue to monitor HGB and for signs of nausea, light-headedness, weakness. Pt has ARF and chronic anemia.

Hematocrit 35-47 26.6 trend ↓ 27.9 26.4 Below NR. Decrease in RBC and HGB results in a decrease in HCT. Continue to monitor HCT and for signs of nausea, light-headedness, weakness. Pt has ARF and chronic anemia.

PLT COUNT 150-400 516 trend ↓ 520 469 Above NR. Increased PLT increase the risk for developing a clot. This is important because pt stays in bed most of the time. Pt is on Eliquis for clot risk r/t A-Fib. Assess for edema, warmth, redness. Continue to monitor PLT.

CHEMISTRY

N4810 Clinical Paperwork Rev 11/6/13

Potassium 3.5-5.1 3.6 trend ↓ ----- 3.9 WNL. Assess for S&S of hypokalemia: weakness, fatigue, arrhythmias, polyuria, polydipsia. Assess for S&S of hyperkalemia: slow, irregular heartbeat, fatigue, muscle weakness, confusion. Discuss these with pt and potassium diet with them: bananas, avocados, potatoes, etc. Monitor electrolyte balance. Important to monitor K in this cardiac pt because of fatal complications of hypokalemia with heart meds.

Glucose 70-99 2/12 @1200

175

Trend ↓

2/12 @0630

200

2/11 @1200

368

Above NR. The time of day, different forms of stress and drugs can cause increased BS. Pt has Type 2 DM which causes increased blood sugar Monitor for S&S of hyperglycemia: SOB, excessive thirst, headaches and frequent urination. Continue to monitor glucose POC.

Magnesium 1.8-2.4 ----- ----- 1.2 Below NR. Continue to monitor Magnesium levels. Low levels may increase cardiac irritability and aggravate cardiac arrhythmias. Most organ functions depend on magnesium. Pt needs proper electrolyte balance and nutrition for organs to continue functioning normally. Pt is on Mag replacement therapy.

LIVER PANEL

Alk phosphatase 26-137 --- --- 59 LFT’s WNL. Need to be

monitored with

administration of

Tylenol for signs of

hepatotoxicity.

AST 0-37 --- --- 36 LFT’s WNL. Need to be

monitored with

administration of

Tylenol for signs of

hepatotoxicity.

ALT 0-60 --- --- 15 LFT’s WNL. Need to be

monitored with

N4810 Clinical Paperwork Rev 11/6/13

administration of

Tylenol for signs of

hepatotoxicity.

COAGULATTION

PT 12.1-15.3 --- --- 26.1 Above NR. Pt is on

Eliquis which may be

the cause of this

elevation. MD should be

notified to see if dose

needs to be changed.

INR ratio 0.9-1.1 --- --- 2.6 Above NR. Pt is on

Eliquis which may be

the cause of this

elevation. MD should be

notified to see if dose

needs to be changed.

PTT 24-36 --- --- 45.9 Above NR. Pt is on

Eliquis which may be

the cause of this

elevation. MD should be

notified to see if dose

needs to be changed.

UA collection type --- --- unknown The UA indicates that

the pt has a UTI. This

was the reason for the

pt’s ALOC and fall that

led to ER admission.

Administer meds and

monitor WBC, VS, UA.

Urine color Light yellow --- --- Amber

Urine appearance Clear --- --- Cloudy

Specific gravity 1.003-1.035 --- --- 1.010

Urine Ph 5-8 --- --- 5

Urine glucose Neg --- --- Neg

Urine bilirubin Neg --- --- Neg

Urine blood Neg --- --- Moderate

Urine Ketones Neg --- --- Neg

Urine Nitrites Neg --- --- Neg

Urine Protein Neg --- --- Neg

Urine Leukocytes Neg --- --- 2+

Stool Cultures --- --- Pos A

CDIFF on

2/9 & 1/28

This culture indicates

that pt has CDIFF.

Administer appropriate

meds and monitor WBC,

VS, and cultures.

ABG(FIO2 + device)

pH 7.35-7.45 --- 7.196 --- The pt’s ABG’s indicate

Respiratory acidosis.

Administer

N4810 Clinical Paperwork Rev 11/6/13

Thebronchodilators,

oxygen, Bi-PAP (if

needed) to treat

underlying disease. This

is also related to her

COPD and decreased

cardiac output.

PO2 80-100 --- 82 --- “”

PCO2 35-45 --- 56.8 --- “”

Bicarbonate 20-26 --- 21.5 --- “”

Oxygen Saturation 95-100 98 93 --- “"

DIAGNOSTIC DATA Student Name: Ikneet Kandola

Transthoracic Echo 1/18/15 1707 A fib w/ mild left ventricular hypertrophy.

Mild mitral and tricuspid regurgitation. PA

pressure: 33mg norm.

ECG 2/9/15 @0650 Ventricular rate: 112; atrial rate: 111; QRS:

82ms; QT: 332 ms. Dx: A fib w/ rapid

ventricular response.

CT chest with contrast 2/11/15 @ 1343 Proximal abd aortic pseudoaneurysm

mostly thrombosed.. 6mm nodular

component of active arterial flow.

Recommend imaging to abd pelvis to assess

extent of disease.

CT abd Pelvis 2/11/15 @1938 Possible upper abd aorta hematoma. Mild to

moderate bilat pleural effusion.

WBC Body scan 2/12/15 Results pending

NOTE: This outline of labs and diagnostics is to be organized by each student it is NOT all inclusive

you must decide what labs are important. Not all labs on this list will be found on each patient.

N4810 Clinical Paperwork Rev11/06/13

Concept Mapping Student Name: Ikneet Kandola

List NANDA nursing diagnosis, supporting data, and interventions. List Supporting Data under each nursing diagnosis to support each

diagnosis, including lab data, medications, assessment findings in clockwise order. List Interventions for Each Nursing Diagnosis. All

medical & nursing interventions should be found in one or more of the boxes. Evaluate Each Nursing Diagnosis on the following page.

2. Infection

Data to Support:

WBC: 16, UA reveals UTI, Stool

culture reveals CDIFF

Interventions:

Flagyl

Vancomycin

Contact isolation precautions

Monitor temp & WBC

1. Decreased cardiac output

Data to Support:

ECG: recently diagnosed A-fib, decreased

urine output, diminished lung sounds in the

bases.

Interventions:

Cardizem

2L NC

Monitor I&O, ECG for changes

5. Knowledge deficit:

Data to Support: Pt has

uncontrolled type 2 DM. Does

not know the consequences of

this which can already be seen

in her body: retinopathy, &

peripheral neuropathy.

Interventions:

Educate pt about importance of

controlled DM.

Promote CCC diet & glucose

monitoring at home. 3. Activity intolerance Data to Support:

Pt has decreased cardiac

output so she has

imbalance between

oxygen supply and

demand. SOB when

repositioning in bed.

Interventions:

Promote rest

Use oxygen

Chief Medical Diagnosis: Severe sepsis r/t

UTI (ALOC & fall), recurrent CDIFF. COPD,

Type 2 DM, ARF

Priority Assessments:

Respiratory assessment: WOB, VS, O2 Sat,

LOC, Auscultation of lungs. Pain level, Fall-

risk assessment, Monitor labs: CBC, BMP,

electrolyte balance. Monitor I&O.

Continuous ECG monitoring. CSM: check

legs, heart, and lungs.

6. Discharge

VS stable

WBC 5-10

O2 95-100

Finish antibiotic regimen

Discharge to rehab: med

reconciliation (insulin pens)

Control diabetes & f/u w./ PCP

8. Education

- Taught diabetic diet: CCC diet.

- Taught S&S of hypoglycemia

and of hyperglycemia.

- Taught purpose of WBC Body

scan test

- Denture care

- Newly diagnosed A-fib

4. Decreased Gas Exchange/Oxygenation

Data to Support: COPD (history)

Diminished Breath sounds bilat bases,

Respiration labored with activity

RR=20, fatigued, Hgb = , O2 Sats = 93%

Interventions:

Albuterol tx prn

Duoneb tx by RT

Oxygen 2L NC

Monitor O2 sats, lung sounds & RR

7. Falls

Data to Support:

Pt had fall and was brought

to ER.

Lethargic/Fatigued

Bed rest: ambulates with 1

person assist

Tubes (tripping)

Interventions:

Fall protocol (fall risk sign

up)

Ambulate to chair

TEDS/SCDS

Eliquis

N4810 Clinical Paperwork Rev11/06/13

The case map is good but be more indepth on your interventions and make sure they address your problem. Example Falls why would

TEDs?SCDs be an intervention to prevent falls. Why would you give Eliquis for falls??? Decrease CO is another one? You should have an

Ejection Fraction to support low CO also make sure you give more objective data to support your DX. Like what was the HR that

decreased the HR was it 130s cardizam IV is usually started with the HR is 150-160 But overall good job for first one

Problem Evaluation

Problem # Evaluation of Patient Response

1

Decreased Cardiac output

Pt does not display hemodynamic stability: BP is elevated s/ meds, cardiac output is decreased r/t A-fib, urinary output is <30mL/hr, and peripheral pulses are weak. Pt did not display any mental status changes, hypoxia w/ activity and is on continuous 2L NC which promotes cardiac function by increasing available oxygen that is being consumed. Pt’s lung sounds are diminished which can be correlated to ARF. Pt was educated about the importance of medication adherence and rest for this dx.

2

Infection

WBC is above NR. Temp is WNL. Mucus production is clear in color. No signs of resp infection. Pt is still on antibiotics. Urine is amber in color in the foley bag. UA reveals UTI. Pt will be sent to rehab with antibiotics and was instructed by SN to complete all of the meds even when feeling better to avoid future infections and resistance. Pt agreed to do so. Antibiotics were administered: Flagyl & Vancomycin. Pt maintained good hygiene: bed bath and oral hygiene: linen and gown change. Pt did not need to be suctioned. Pt effectively coughed and secretions were removed. Pt understood the importance of removing secretions.

3

Activity intolerance

Ambulates with assist. She ambulated 1x my shift. Pt’s breathing becomes labored when she tries to reposition in bed. Pt was instructed to let me know if she felt that she needs assistance. Pt was asked to perform ROM exercises in bed. Pt tolerated well. These ex were done with 2LNC to promote better gas exchange and decrease difficulty breathing during activity. Pt was told to increase activity gradually and that will build tolerance. Pt’s family was taught about ambulation assistance. Pt will be sent to rehab and she agreed that it was necessary.

4

Decreased gas exchange/oxygenation

RR, depth, and effort is WNL. WOB is increased with activity. Doesn’t use accessory muscles, nasal flaring, and no abn breathing patterns noted. Breath sounds diminished in lung bases bilat. LOC is A&O X4. No signs of confusion, restlessness, or agitation. O2 sat remained in high 90’s during

N4810 Clinical Paperwork Rev11/06/13

shift. No presence of cyanosis. Pt was taught pursed-lip breathing and its benefits in COPD. HOB was elevated at all times. NC 2L was given. Respiratory treatments w/ DuoNeb pending (waiting for RT).

5

Knowledge deficit

Pt has knowledge deficit about the complications of Type 2 DM. Pt recently lost her spouse and her health is deteriorating. At this time, family teaching is critical but pt’s daughter did not come during my shift but some teaching was done with the pt’s sister and niece. Pt nodded understanding upon teaching of her health conditions. Rehab can serve as a venue for her to improve her overall health.

6

Falls

Pt is A&O x4. No longer ALOC. Assisted pt w/ ambulation x1. Call light was within pt’s reach and pt was instructed to press the nurse button when she needed me. Pt was wearing non-slip socks. Some of his meds have s/e of confusion and dizziness. Pt has fall risk sign outside his room and the armband. Pt tried to climb out of bed but bed alarms were on and I helped her immediately. Bed alarm is on for pt’s safety and room is close to Nurse’s station. Bed was low at all times and bed rails were up x2. Pt was calm during my shift and asked to be ambulated out of bed.

N4810 Clinical Paperwork Rev11/06/13

Student Clinical Self-Appraisal EXAMPLE

Weekly (turn in with Care Plan/Map)

Student Ikneet Kandola Course N4810_____ Instructor Sherri Brown Instructions: Please evaluate your performance during clinical today using the following concepts: Client Advocate Professional Demeanor Flexible Critical Thinking Communication/rapport Coordinator of Care Self-Initiated Technical skills Team Player Professional Accountability Organized Educator Leadership Well-prepared Ability to Prioritize Nursing Process Comprehensive Assessment Knowledgeable

Areas of Strength Today (Date) 2/12/15 Client Advocate: Most of the staff does not gown up for pts in contact isolation for CDIFF. This is a breach of safety because it can cause the spread of disease and bacteria. I gowned up every single time even when I was told I didn’t have to. Self-initiated: I asked my nurse that I would like to get new tubing for the antibiotic I was hanging because the previous one did not have a label. I also labeled the new tubing that was changed. Communication/rapport: I build rapport with my patient to the level that we were ok joking around with each other and laughing. I love it when I can get to that level with a patient because I can do my work and have fun all at the same time. Well-prepared: I did all of my prep work a day ahead and knew what to look for when I went in that morning. Team player: I let my pt’s CNA know that I am the SN and I am here to perform any CNA duties that she needs help with or those that I can perform on my own. I also offered my services to the RN.

Areas Needing Growth-Include plan of improvement : Organized: Coming back to the floor after a whole semester, I felt that my notes were disorganized and I need to get back on my usual ways of organizing. Technical skills: I had computer training 2 semesters ago for MMC. I felt very lost with the computer system but as the day went by I figured it out. Oh and I spent 4+ hours the day before figuring out the computer system. I would definitely go through the training again next time. Professional accountability: my nurse documented that she applied the ointment for the buttocks but she never did!!! I saw this in the computer and I asked her and she said yes I applied it. When I asked my pt she said no. Clearly my pt was A&Ox4 and knew what was going on. What do I do in this case without possibly questioning the nurse’s integrity? Ethical dilemma! Ahhhh!

N4810 Clinical Paperwork Rev11/06/13

Instructor Comments: It is very difficult to play the middle and still question the nurse when you are questioning what they did. It is always just good to play dumb and say something like the patient didn’t remember having ointment put on would you like me to do it for you? Ethical dilemma will be every day you work. I am so very excited to see you get out of school and practice. MaryAnn used to tell me what a great student Nurse you were and I see that you have in incredible work ethic and a drive to understand everything you can to best meet the patients need. You are going to be excellent. The case Map was good I am just looking for more depth and next time stay away for things you used in 2910. You have a great understanding of things. Keep up the good work!!!

Student’s Name: Ikneet Kandola Pt’s Initials: DJ Date: 02/12/15

Atrial rhythm: Regular or Irregular Ventricular rhythm: Regular or Irregular

Atrial Rate____________________ Ventricular rate _______________________

PR interval ___________________ QRS interval ________________

QT interval____________________

Is AV conduction normal? (Y/N)______________ If not, why is it abnormal?

________________________________________________________________________

P wave normal? (Y/N) ________ QRS complex normal? (Y/N) ________

I was going to do this portion on Day 2 but clinical was canceled. Sorry

N4810 Clinical Paperwork Rev11/06/13

Are all of the QRS complexes the same? (Y/N) ___________________

Are there premature beats? (Y/N) __________ , Atrial or ventricular

Interpretation of rhythm:

A-Fib

Potential hemodynamic consequences of this rhythm and interventions for this rhythm:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

N4810 Clinical Paperwork Rev11/06/13

Student Name: Ikneet Kandola Date: 02/12/15 Clinical Instructor: Sherri Brown

Instructions: Attach a copy of this form to the back of each of you Clinical Plan of Care/Maps for grading purposes. Grading Rubric:

1. Patient Data includes: 20 points possible __20___ a. Health history b. All blanks and/or issues are addressed

2. Each medication includes: 20 points possible __20___ a. Name b. Rationale c. Side effects d. Nursing implications-specific to this patient

3. Lab Diagnostics 10 points possible ___8__ a. Test b. Results c. Implications & Teaching

4. Problem Identification includes 20 points possible __18___ a. Correctly lists individualized needs b. Correctly identifies problems c. Problems are prioritized and numbered, each problem in priority of importance d. Map includes at least five physiological problems, discharge planning and patient education e. Each problem includes:

i. Nursing diagnosis ii. Data to support iii. Medication iv. Nursing treatment (interventions)

5. Planned interventions includes 10 points possible ___10__ a. Interventions appropriate b. Correctly prioritizes interventions c. Assessments performed d. Communication e. Patient teaching f. Discharge planning

6. Evaluation of Interventions includes 10 points possible ___10__ a. Evaluates physical interventions b. Evaluates teaching

7. a. Priority Assessments are appropriate to diagnoses 10 points possible ___10_ b. Clinical Paperwork is complete

Total Points ______96_______/100 = ____%