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CSU, STANISLAUS B.S.N. CLINICAL PLAN OF CARE
Patient Data
Student ALYSSA CARDINAL Date of Care: 2/26-2/27/15 Room Number: S4741 Code Status: Full Pt. Initials: D.S. Gender: MALE Age: 55 Height: 5’11” Weight: 82kg (180lb) BMI: 25.1 Spirituality: Non-specified Ethnicity: CAUCASIAN Admitting Diagnosis: ASPIRATION PNEUMONIA (r/t COPD exacerbation) Vital Signs (2/27 1215): Temp: 98.3 HR: 104 RR: 22 B/P: 135/80 O2 Sat: 98% RA (Trach collar) Pain Scale & Scale Type: 8/10 (0-10 scale) History related to this admission: COPD, ASTHMA Past Medical History: UPPER ESOPHAGUS METS TO A SUPRACLAVICULAR NODE (Dx 2014)- has undergone 3 cycles chemo/XRT, TRACHEOSTOMY, HTN, LUMBAGO, PAIN IN LIMBS, PVD-INTERMITENT CLAUDICATION, TOBACCO USER, DISORDER OF KIDNEY AND URETER (unspecified), COPD, HYPERLIPIDEMIA Surgical History & Date: • Difficult intubation (6/3/14) MD: Olgun, Esra Diet: Clear liquids (as tolerated); PEG feeding w/ Osmolite 1.2, 2016 calories, 93g protein Activity: bed rest with 1 person assist to bedside commode Foley: none Feeding Tube & Rate: PEG- Osmolite 70mL/hr Advance Directive: Yes ________ No ___X____ Drains/ Tubes: PEG, Trach (placed 10/10/14, SZ 6
Shiley) Isolation: no VS Freq: Q4H Glucose Monitoring: Q6h DVT Prophylaxis: Active ROM, SCDs (pt refuses), position changes Vascular Access: IV Site: Peripheral- rt hand IV Solution & Rate: NS 50mL/hr IV Site: Implanted port, rt infraclavicular fossa- (no access until blood cultures come back negative) PCA/Epidural: none Telemetry & Rhythm: 5 lead; 0300- sinus tachy- HR 116 Safety Considerations: Aspiration precautions, Fall risk, Pressure ulcer prevention Restraints: none Labs for day of clinical: CBC, phosph, Mg+ Dressing Changes & Frequency: PEG dressing change Qshift, Trach care Q12h Scheduled Procedures: sputum culture, stool
culture Procedures done this admission: EKG (2/27/15 )- rate 126, sinus tachy, normal intervals, no STEMI CXR (2/24 2225)- cardiomegaly, small pleural effusion, no pneumothorax CT w/ Contrast (2/25 12:04AM)- bilateral lung nodules and mass in RLL, metastatic disease, pleural space unremarkable, no significant effusion, no pneumonia, trace pericardial effusion, CA calcifications, no PE, trach tip in good location, old bilateral rib fractures, cyst in dome of rt lobe liver, small hiatal hernia; Echo w/Doppler (2/25 1600) r/t syncope
Oxygen: RA w/humidification via T-piece Respiratory Treatment: Yes; ipratropium/albuterol (Duoneb) Q6h Vent Settings: not on vent Advanced Hemodynamic Monitoring & Values: None IV Drips Medications Dosage & Rate: none (IV antibiotics listed in Meds)
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Concept Mapping Student Name: _Alyssa Cardinal__
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. Impaired Gas Exchange Data to Support: Dx of COPD, coarse crackles, resp labored with activity; RR=22 resting, é RR w/activity Interventions: Assess O2 sat, administer O2 during periods of dyspnea, administer humidified RA to liquefy congestive secretions and improve breathing, elevate HOB to improve effectiveness of respirations. Meds: Duoneb (bronchodilator) and Advair (corticosteroid)- égas exchange by opening the airways, assess ABGs
1. Ineffective airway management Data to Support: Trach, thick, copious secretions, difficulty expelling secretions Interventions: Assess O2 sat, RR and ease of breathing, administer O2 during periods of dyspnea, administer humidified RA to liquefy congestive secretions and improve breathing, elevate HOB to improve effectiveness of respirations. Encourage cough and assist with cough as needed. During episodes of partial or complete airway occlusion r/t mucous plug, rapidly push 10mL NS directly in to trach to mobilize secretions and assist with expulsion. Meds: Duoneb (bronchodilator) and Advair (corticosteroid)- égas exchange by opening the airways
5. Risk for aspiration Data to Support: Dx of COPD (excessive fluids) with trach and difficulty expelling mucous, ineffective/depressed cough, heavy pain medication administration, decreased GI mobility and tube feedings, impaired swallowing, previous aspiration on admission Interventions: Assess cough, gag reflex, swallowing ability, auscultate bowel sounds for GI motility, assess lung sounds for crackles/ronchi, suction as needed, elevate HOB, check GT tube residuals
3. Excess fluid volume Data to Support: Dx of COPD, coarse crackles in lungs, generalized edema Interventions: Auscultate lung sounds, Monitor I&O (Consult with physician to consider starting pt on diuretic therapy)
Chief Medical Diagnosis: COPD Priority Assessments: Pt is at risk for respiratory failure, so monitoring lung sounds, RR, ease of breathing, and O2 sat is crucial. Pt also has a trach, cancer, and PVD, so trach patency, pain management and effective tissue perfusion are important for this pt as well.
4. Anxiety r/t pain management Data to Support: Pt frequently requesting pain medication and asking when the next dose of Dilaudid or oxycodone can be administered, pt appears agitated prior to administration of pain meds Interventions: Assess pt’s pain level and administer pain medication on time, write analgesic schedule on pt’s whiteboard to relieve anxiety of when next dose will be administered, reassure pt that his pain meds will be received as quickly as possible to manage pain levels, (Consult with physician to consider adding an anti-anxiety to pt’s medication list)
6. Risk for bleeding Data to Support: Platelet count 32, multiple scattered bruises on lower extremities Interventions: Assess skin for wounds, bruising, prolonged bleeding at puncture sites, monitor PLT count and coagulation studies (no PT/INR in pt labs), monitor VS for decreased BP and increase, use soft toothbrush and electric razor to prevent injury, fall precautions.
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Student Name: __Alyssa Cardinal__
Problem Evaluation
Problem # Evaluation of Patient Response
1 (0800)- O2 sat 96% on humidified RA, generalized coarse crackles, RR 19, no
dyspnea. HOB elevated. Infrequent mildly productive cough. (0845)- Dyspnea r/t mucous plug occluding airway. FiO2 increased, O2 sat
dropped to 91%. Removed pt’s inner cannula and flushed trach w/ NaCl x3. Pt coughed and expelled plug. O2 sat increased to 98%. Inner cannula replaced.
(0900)- Meds administered (0930) Crackles in bilateral bases, no dyspnea
2 (0800)- O2 sat 96% on humidified RA, generalized coarse crackles, RR 19, no
dyspnea. HOB elevated. Infrequent mildly productive cough. (0845)- Dyspnea r/t mucous plug occluding airway. FiO2 increased, O2 sat
dropped to 91%. Removed pt’s inner cannula and flushed trach w/ NaCl x3. Pt coughed and expelled plug. O2 sat increased to 98%. Inner cannula replaced.
(0900)- Meds administered (0930) Crackles in bilateral bases, no dyspnea
3 (0800)- Generalized coarse crackles, intake- 120 mL/hr, output- 375mL
(0930) Crackles in bilateral bases (1030)- Intake- 120 mL/hr, output 250mL
4 (0715) Anxious behaviors r/t pain. Pt continuously asks for pain medication
schedule. Pain 7-8/10. (0745) Administered Dilaudid.
(0800) No observable anxious behaviors, pain 5/10. (1010) Anxious behaviors r/t pain. Administered oxycodone.
(1030) No observable anxious behaviors, pain 5/10.
5
(0800)- Infrequent, mildly productive cough. Generalized coarse crackles. Adequate swallow. BS active x4.
No gastric residual. HOB 45 degrees. (0930) Crackles in bilateral bases
6 (0800)- PLT count 32, scattered bruises on lower extremities, no current bleeding
from puncture sites. Generalized coarse crackles. BP127/76, HR 116. Fall risk and bleeding precautions implemented.
(0930) Crackles in bilateral bases (1215) BP135/80, HR 104
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Medication: Generic & Trade Name, Dose, Route, Frequency
Mechanism of Action & Class Pt Specific Rationale Nursing Considerations (Assessment implications, S/Es, reasons to hold med, admin rate, etc.)
vancomycin 1250mg in 250mL NS, IVPB Q12h
Tricyclic glycopeptide antibiotic; primarily inhibits bacterial cell wall synthesis to destroy bacteria and treat infection.
Pt has extremely elevated WBC indicating infection. Vanco will tx the pt's infection.
Hypokalemia (CHECK K+), n/v/d, cardiac arrest, hypotension, C.diff; Infuse over 1 hour
fluticasone propionate salmeterol (Advair), 250mcg/50mcg oral inhalation, 1 puff Q12h
Adrenal glucocorticoid, anti-‐inflammatory, corticosteroid; Glucocorticoids inhibit mast cells, eosinophils, basophils, lymphocytes, macrophages, and neutrophils, while also inhibiting production or secretion of cell mediators such as histamine, leukotrienes, cytokines and eicosanoids.
This pt has COPD and asthma. This drug will reduce inflammation and prevent exacerbations.
Candidiasis of mouth-‐ rinse after use. Cough, nosebleeds, upper respiratory infection, pneumonia-‐ observe for sx of infection and monitor WBC. Teach pt that this drug is not for acute attacks and may take a few weeks to see results. Plug trach during administration of this med.
metronidazole (Flagyl); 500mg in 100mL NaCl IV Q8h
Antibiotic; selectively produces cytotoxic effects in anaerobes by a reduction reaction, depriving the organism of required reduction equivalents.
Pt has extremely elevated WBC indicating infection. Vanco will tx the pt's infection.
Abd discomfort, n/d, peripheral neuropathy, ototoicity; Infuse over 1 hour
piperacillin sodium/tazobactam sodium (Zosyn), 3.375g in 100mL NS IVPB Q8h
Penicillin antibiotic; a bactericidal that inhibits bacterial septum formation and cell-‐wall synthesis to treat infection
Pt has extremely elevated WBC indicating infection. Vanco will tx the pt's infection.
constipation or diarrhea, n/v, fever, C.diff, pancytopenia; Infuse over 1 hour
acetaminophen (Tylenol) 650 mg oral Q4h PRN
analgesic/antipyretic-‐ centrally acting COX-‐2 inhibitor that elevates the pain threshold, thereby reducing pain levels. Reduces fever by inhibiting the formulation and release of prostaglandins.
This pt has pain constant aching pain caused by trach and cancer. This med will treat his fever.
4 g/day max to prevent liver failure (hepatotoxicity, GI hemmorhage, or nephrotoxicity). Stevens-‐Johnson syndrome. Take with full glass of water
hydralazine (Apresoline), 10mg IV Q4h PRN for SBP >160
Peripheral vasodilator/antihypertensive; relaxes vascular smooth muscle by interfering with Ca+ movement responsible for initiating or maintaining the contractile state within vascular smooth muscle.
Pt has HTN. This med acts quickly to reduce BP.
Administer each 10mg over 1 minute. Hepatotoxicity, agranulocytosis, n/v/d, loss of appetite, chest pain, palpitations, tachyarrhythmias.
Hydrocodone/ acetaminophen (Norco-‐10) 10mg/325mg 1 tab oral Q4h PRN
Opioid agonist analgesic; Acts on the CNS to fill opioid receptors causing pain relief
This pt has pain ranging between 7 and 9. This med will reduce his pain to enhance comfort and reduce anxiety r/t pain.
n/v, dizziness, Stevens-‐Johnson syndrome, agranulocytosis (check WBC), thrombocytopenia (check plt count), hepatotoxicity, respiratory depression (check RR before and after administration). Do not exceed more than 4000mg acetaminophen daily. Teach pt to report s/s of resp depression. Do not ambulate after administration of this med due to dizziness.
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hydromorphone (Dilaudid), 2mg IV Q3h PRN
Opioid agonist analgesic; Acts on the CNS to fill opioid (mu) receptors causing pain relief
This pt has pain ranging between 7 and 9. This med will reduce his pain to enhance comfort and reduce anxiety r/t pain.
Constipation, n/v, hypotension, resp. depression, apnea, avoid activities requiring mental alertness. Administer over 2 minutes.
ipratropium/albuterol (Duoneb), 0.5 mg/ 2.5 mg/ 3 mL, oral inhalation Q6h RT
Beta 2 adrenergic agonist/ bronchodilator/ sympathomimetic/ anticholinergic. Albuterol is a sympathomimetic/beta 2 agonist that activates these receptors to relax the smooth muscles of the airway. Ipratropium is an anticholinergic that produces a local effect (opposed to systemic) that causes bronchodilation.
This pt has COPD with a recent exacerbation. It is therefore important to maintain a relaxed, dilated airway to enhance oxygenation and prevent another exacerbation. This is a short acting med in comparison to the Symbicort.
This med can cause GI disturbances, upper resp. infections, arrhythmias, bronchospasm, blurred vision and dizziness. Remain in bed after administration of this med to prevent falls.
sucralfate (Carafate), 1g/10mL, 1 g Q10-‐30min before meals and at bed
Antiulcer; forms an ulcer-‐adherent complex with proteinaceous exudate, such as albumin and fibrinogen, at the ulcer site, protecting it against further acid attack. Also forms a barrier on the stomach to protect from further damage.
This pt is receiving many medications that cause GI irritation. This med will prevent acid erosion/irritation of the stomach lining to prevent GI ulcers.
Constipation, albumin toxicity in pts with renal failure
ondansetron (Zofran), 2mg/mL, 4mg IV Q6h PRN
Antiemetic, Serotonin receptor antagonist; Prevents nausea by blocking 5-‐HT3 receptors peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone.
This pt is in constant pain and has anxiety r/t his pain. This often leads to nausea. This med will reduce the pt's nausea, making him more comfortable.
Constipation, diarrhea, increased liver enzymes, headache, fatigue, malaise, prolonged QT interval
oxycodone (Roxicodone), 10mg oral tab Q6h PRN
Opioid agonist analgesic; Acts on the CNS to fill opioid (mu) receptors causing pain relief
This pt has pain ranging between 7 and 9. This med will reduce his pain to enhance comfort and reduce anxiety r/t pain.
Constipation, n/v, hypotension, resp. depression, apnea, avoid activities requiring mental alertness.
temazapam (Restoril), 15mg oral cap at bed PRN insomnia
Benzodiazepine/Hypnotic; Enhances the effects of GABA to produce a calming effect on the body.
This pt has anxiety r/t pain, which often causes insomnia. With an unstable, unfamiliar hospital environment, it is easy to become anxious. This med helps ease anxiety to make sleep easier.
Hypotension, somnolence, lethargy, avoid activities requiring mental alertness, teach pt to report abnormal thoughts/behaviors. This drug is not taken on a regular basis, used as needed for insomnia.
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LABS Normal Range
RESULT 1
RESULT 2
RESULT 3 Reason for abnormal lab values r/t diagnosis & nursing implications
(Fill in Hospital Norms)
CBC (2/24) 2155
(2/25) 0406
(2/27) 0421
WBC 4.0-11.0 23.1 H 27.0 H 26.5 H Infection likely r/t aspiration on admission
RBC 3.9-5.4 3.62 L 3.62 L 2.75 L Cancer causes decreased RBC production
Hemoglobin 11.7-15.5 12.5 L 12.4 L 9.3 L Cancer causes decreased RBC production
Hematocrit 35-47% 34.2 L 34.8 L 26.6 L Cancer causes decreased RBC production
MCV 80-100 95 96 97
MCH 27-33 34.5 H 34.3 H 33.8 H Poorly oxygenated blood
MCHC 31-36 36.5 H 35.6 H 35
RDW <16.4% 15.3 15.3 15.6
PLT COUNT 150-400 35 LL 32 LL 38 LL!
This pt is not on any blood thinners or other medications that reduce plt count. The reason for thrombocytopenia is unknown- This pt does have a bacterial infection which can cause destruction of platelets. This pt could also has
PVD which can lead to clotting and therefore a large abundance of platelets in one area, reducing the total systemic platelet count.
WBC DIFF NEUTROPHIL % 49-74% 78% H 71 H Infection
BANDS % 11 H% 19 H Infection LYMPHOCYTE% 26-46% 1 L 1 L Infection
MONOCYTE % 49-74% 6% 4
CHEMISTRY
Sodium 136-145 120 L 121 L 130 L This pt has had diarrhea prior to admission which causes hyponatremia. However, he has been on continuous IV NS since admission. Treatment team should consider increasing rate of IV NS to normalize sodium levels.
Potassium 3.5-5.1 3.4 L 4 3.7
Chloride 98-107 83 L 82 L 95 L CO2(bicarb)venous 21-32 31 29 27
Glucose 70-99 93 107 H 128 H High stress levels on the body, including the heart, cause an increased glucose level. The pt is also on a corticosteroid for COPD, which can cause hyperglycemia.
HbA1C
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Calcium 8.2-10.2 7.4 L 8.2 7.5 L Low calcium levels are likely r/t malnourishment, as kidney function tests came back normal. Because this pt
hasn't had a BM in 3 days and has abd distention, there is a possibility he has an ileus, leading to poor nutritional absorption and therefore hypocalcemia.
phosphorus 2.5-4.9 2.9 7.5 L Poor oxygenation leads to impaired cellular energy (ATP), which has a direct effect on phosphorous levels
Magnesium 1.8-2.4 1.8
BUN 6.0-25
Creatinine 0.6-1.10 0.77 0.78
HDL 0-100
LDL 0-200
Cholesterol 0-150
Triglycerides
LIVER PANEL 6.4-8.2
Total protein
Albumin 0-1.1
Bilirubin Total 26-137
Alk phosphatase 0-37
AST 0-60
ALT 73-393
Lipase
Amylase
Ammonia
Lactate
Serum Ketones CARDIAC PANEL
CPK
CPK-MB
Troponin I 0-0.5 2.02
Myoglobin
BNP 0-300 3415 High BNP=CHF!! Although this pt does not have a dx of CHF, he does show many symptoms including fluid overload (edema), HTN, and tachycardia.
COAGULATTION
PT
INR ratio
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PTT
Fibrin level
Bleeding time
D-Dimer 0-250 715
Testing D-Dimer is important when there is a suspicion of deep venous thrombosis (DVT), pulmonary embolism (PE) or disseminated intravascular coagulation (DIC). This pt has thrombocytopenia, which could indicate a clot. He also has PVD and a recent COPD exacerbation, which can lead to clots. An elevated d-dimer suggests he may
have a clot.
UA collection type
Urine color Urine appearance
Specific gravity
Urine Ph
Urine glucose
Urine bilirubin
Urine blood
Urine Ketones
Urine Nitrites
Urine Protein Urine Leukocytes
URINE MICRO
WBC HPF
RBC HPF
Nitrate HPF
Epithelial
Bacteria
Mucous URINE CULTURE
CSF
• WBC 0-5.0
• RBC 0-2.0
• Glucose negative negative
• Protein negative negative
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• Culture negative negative
Blood Cultures
Stool Cultures
Nasal Cultures ABG(FIO2 + device)
pH 7.35-7.45 7.545 H alkalosis
PO2 80-100 63L hypoxemia
PCO2 35-45 34L respiratory alkalosis- r/t hyperventilation (COPD exacerbation)
Bicarbonate 24-26 28.7 H alkalosis Oxygen Saturation 95-100 93 hypoxia
Anion gap 10-20.0 9.4 L A low anion gap in this patient is caused by the COPD exacerbation and elevated HCO3-, resulting in metabolic alkalosis. I would have liked to have seen an ABG for this patient.
Lactate 0.4-‐2.0 1.2
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Student Clinical Self-Appraisal Weekly (turn in with Care Plan/Map)
Student: Alyssa Cardinal 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) Critical thinking: This pt’s case was very complex and I feel I did well thinking outside of the lines to determine some of his clinical manifestations. Technical skills: I felt so much more comfortable using the monitors and starting IV meds today. Communication/rapport: I formed an excellent rapport with my pt and nurse this week. This facilitated my learning experience and made the day go by so much faster and easier.
Areas Needing Growth-Include plan of improvement Organized: My organization this week was far better, but I could definitely use improvement in this area. Knowledgeable: As I’m still learning the pathophysiology behind advanced heart and lung disorders and their associated lab values and treatments, I need more time learning and retaining these topics. Comprehensive Assessment: Although I felt my assessments were better this week, they still need the most improvement.
Instructor Comments: Case Map problem #3- I loved your entire case map great job the only thing I have issue with is your fluid overload. You need to support it more. I/0 ratio etc. Because the trach secreations could be causing the airway changes. So you need to support it more, you could have increase BP, more input then output. And other objective data. I love having you in clinical you are a smart young lady who will be a great nurse. Make sure your entire care plan matches throughout.
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Student Name: Alyssa Cardinal Date: 2/12/15 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 __18___ 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 __20___ 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 = ____%