September 22,201 Time activity plan 5:30 5:45 5:45 6:00 6:00 6:40 6:40 6:50 Check crash

rash cart Prepare things/ check chart Endorsement Assessment VS PE documentation CBG monitoring Prepare suction Give esomeprazole Oral care Prepare meds IV Oral meds Oral feeding Elevate HOB Check placement Hook IV Give feeding Give oral meds After care Turn patient CPPT Fix bandage/ antiembolic stockings Elevate extremities Comfort measures Finish documentation Copy chart

6:50 7:00 7:00 7:20

7:20 7:30 7:30 7:45

7:45 7:50 7:50 8:00

8:00 -8:10 8:10 8:20 8:20 8:25 8:25 8:30 8:30 8:45 8:45 9:00 9:00 9:30

NURSING DIAGNOSIS Decreased cardiac output r/t altered hearth rhythm s/g chronic atrial fibrillation In effective airway clearance r/t retained secretions Anxiety r/t acute and perceived threat to biological integrity s/t invasive procedures Per diagnoses nurse- centered and patient- centered objectives same as yesterday PROGRESS NOTES:

7:00 AM I assessed the patient and got the following VS: IP-130/80, RR- 20, Hr/pr- 96, P- 36.4 LOC-E4V5M6. Upon assessment the patient one can note that the client is already in room air and tolerates it well. His 02 saturation ranges from 96 to 100% 7:15 AM -7:30 AM After assessment, I took the patient CBG and it real 1pare his 100mg/dl. I then premial esomeprazole. The client then complained of discomfort which is why I elevated the head of his bed. It is well tolerated. The client is also has been IV medication of meropenem I hooked it beforehand so that by the time his oral meds are due, it will also be done. I also took the time to prepare the clients meds and oral feeding the client oral care was also ordened. 7:45 -8:00 AM I positioned the client on the bed because he was go displayed on a lower position. 8:oo 8:29 AM I suctioned his secretions and get minimal whitish loose secretions although there was still marked shonchi afterwards. It seemed to that the secretions are still not being mobilized by the diet and I put it in back of my mind to perform turning /CPPT on him later. I then proceeded to give his due oral meds and oral feeding. I also took the opportunity to hydrate him since he refused to drink sips of water due to dysphgia and gave extra 30cc of water in his flushing. 8:30 AM Client complained of discomfort so I repositioned him on his bed and elevated the head of his bed. I also put pillow at the base of his head as requested. I also took the time to perform CPPT and to elevate the clients extremities. 8:45 AM I ansultated cackles at the bases of the clients lungs so I encourage him to perform deep breathing so that he can expectorate it later. 9:00 AM Since there was noted pitting edema on both upper extremities, I bandaged his R and l forearms. This is also in conomice with doctor hernandez orders. Before bandage his L forearm I frist waited for his IV medication (mecropen) to be totally infused. As observed, the clients 02 saturation is maintained at 90100%. it is highly liely that he is soon to be transferred to a room/ward. ADDITIONAL LABS:

Blood chemistry- to assess renal and liver functions as well as to detect electrolye imbalance in the body. Normal 65 - 81 35 - 48 2.15 2.5 0.81 1. 49 Actual result 52 16 1.86 1.52

Total protein Albumin Calcium Phosphorus

Interpretation Bacterial screening: to determine the presence of pathogens in respiratory tract ETA MN Squamous epithedol cells Gram (+) cocci in pains Gram(-) bacilli Result <10 <10/ LPF 3-5 /OIF 0-1/ 01F

Interpretation: this culture test of the clients endotracheal aspirate indicate that he has gram bacilli in his respiratory tract. As well as gram (+) cocci in pairs. Based on this future test may required to identify kind of bacteria present so that appropriate antibacterial treatment may be started. JORNAL ARTICLE REACTION Source : Herr, k. Coyne, p. man woman, R- Mccaffery, M. Merket S, pelos Kelley, J wild L (2006) pain assessment in the non verbal patient position statement with clinical practice recommendation American society for pain management nursing VOL7,no2 ( june ) PP. 44-52 The article presents position statement and clinical practice recommendations assessment in the non verbal patient. Here are the important points given in the article: All person T pain deserved prompt recognition and treatment Pain should be motively monitored assessed, reassessed and documented clearly to facilitate treatment and communication among health care clinicians In nonverbal patients alternative methods and assesstment should be used In history of pain assessment involves: 1. Self report 2. Potential courses of pain 3. Potential behaviors 4. Surrogate reporting (significant others etc.)

5. Attempt analgesic trial This article help me in my core because the usual tools for assessment (VAS, faces pain scale) were not adequate to assess pain when the client was still intubated. This was especially helpful when when we had a discrepancy in documentation of analgesia score. This supports the assertion that the patient self report is still the number one tool for pain assessment. All in all the journal article made my assessment of the fifth vital sign ( pain ) more accurate and realiable. HIGHLIGHTS Today I got the opportunity to again rely on GODs grace. Despite the nausea and weakness that I still feel, I was able to perform my functions as a nurse even though I do not have a partner just like my other classmate I m very thankful of it already. Again Ive learned a lot from our master students as they supervised us in the bedsides. The inter actions with them via case presentation also proved useful for me. They got to verify my PE findings and I am glad that these findings are in congmence with theirs. Today, I have also learned the value of time management I believed that today. I have finished earlier than usual because by 8:30, I was just waiting for my IV medication to be totally infused so that I can complete my comfort measure requires by putting bandage on my clients left hand. I am also very happy about the progress that my clients making as he is doing quite well and is nearing transfer to ward. Nurse- centered obj. Nurse will: 1. 2. 3. 4. Implement plan of of come as planned Manage time by sticking to time and activity plan as appropriate Assess patients states thoroughly Perform CPPT suctioning turning and appropriate Clients- centered obj. Clients will: 1. Display hemodynamic stability 2. Report episodes of dyspnea 3. Demonstrate effective expectoration of secretions 4. Demonstrate decrease agitation/ lessened anxiety September 23, 2011 PROGRESS NOTES Name of patient: Ernesto Mendoza Date of admission: 9/14/2011

Medical diagnosis: hcesophageal mass, ARF, azotemia Endorsement: Heplock at L- metacarpal vein give frequent sips of water NGT Oral feeding 222cc

apply elastic bandage-re Least 8 am for condom catheler insertion for possible trans out apply antiembolic stockings (on washing)

6:30 AM I received the patient asleep so I did not wake him up yet, instead, just like yesterday, I assessed what I could do at that point. I noticed that his RR is 22 bpm, his HR is 80 bpm. After a while he woke up and his BP was 140/ 70 mm/tg. His e4v5m6. My PE assessment/ findings are follows: >conscious conherant, looks according to age, appears cachexic > VAS 2/10 >pale skin, (+) milky discharge @L-forearm >fair turgor, rough, dry skin >normocephalic head, fine hair, clean scalp, (-) masses >symmetrical lids, pale conjunctiva >anisteric sclera, equal pupil size 3mm >brisk reaction to light, uniform accommodation, uniform convergence >normoset ears,(-) discharge >pale lips, tongue @ middle, completely missing teeth, pinkish gums, pinkish mucosa >symmetrical masolabial folds >R nostril patent, L nostril T NGT >non tender sinuses >trachea at midline >non plalpable lymph, nodes >flot percordical area, PMI@ 5th ICS LMCL, apricot beat @4th LCS > s I <s2@ base, sI >s2 @ apex >distinct but irregular heart sounds > 1:1 I/E ratio >1:2 APL ratio >(+) occasional rhonchi @ bilateral lung fields >globular abdomen, (-) lesions >normoactive bowel sounds : 19/min >(-) muscle guarding, (-) tenderness >peripheral pulses and assessed d/t edema >pale nailbeds CRT= 3 sec. >(+) peripheral edema, grade 2, pitting CONTRAPTIONS: T heplock @L-metacarpal vein, (-) entherma, (-) tenderness,(-) warmth

Others: room air well tolerated, 02 sat. 96- 100% ECG: a. fibrillation T occasional PVCs 7:00 AM The nurse took his CBG and it read 190 mg/dL. Because of this he was given 4 units of insulin (SAI) vai subcuntanious roule at abdomen RLQ (8AM). 7:05 AM I prepared his premeal esomeprazole so that he can have it before the 8 Am feeding. Next because the client has andible rchonchi. I encourage him to expedorate by teaching him how to perform huff cough and deep breathing. He expectorated moderate yellow- brown thick sputum. 7:15 AM The client was given his due esomeprazole via NGT after the HOB was elevated and the NGT placement was checked. It was well tolerated. 7:20 AM Oral care was done using Bactidol and cotton pledgets 7:23 AM I offered the client sips of water. He sipped about 10 cc of water 7:23-7:55 AM Prepared meds: IV-Meropenem in 10cc sterile water Oral-moriamin forte -rebepamide in 10cc distilled water, strained w/ GAUZE -dolcet -aldactone 7:55-8: 00 >elevated haed of bed to 30 degree, well tolerated >checked NGT placement, in place and intact >oral feeding given well tolerated >oral medications given well tolerated >IV medication meropenems soluset was prepared but my buddy nurse told me to give the newly ordered d5050+HR to the client first since the client only has one line. 8:19 AM >after come done 8:20 AM >turned patient to R lateral side >CPPT done (pulmonary clapping) >still T non productive conghing 8:30 AM >Adible shonchi, (+) non productive coughing > encourage client to perform deep breathing

>taught huff coughing >encourage to sip water approx 30 cc volume >still T nonproductive cough 8:40 AM >Bandage on forearms in tack in place >loosed bandage in L and R forearm as ordered >L and R forearm (+) for edema grade 1, pitting 8:45 AM >elevated extremities as ordered > well tolerated 8:50 AM >02 saturation monitor broken >BP apporks tubings broken >attempled to fix 02sat monitor and BP apparatus >BP apparatus was fixed but 02 saturation monitor remained broken 9:00 AM >Assisted PT Ms. Fernandez in passive and active ROM exercises >well tolerated 9:30 AM >Condom catheler applied using aseptic techniques >(-) discharge penis (-) inflammation >patient T condom catheler draining to urine bag 9:40 AM >Noted nonsoaked diaper(+) urine, light yellowish (-) stool >changed diaper >T diaper intact well tolerated 9:50 AM >Appeared not in neutral position >repositioned on bed >arranged pilliow to accomoderate head and shoulder >elevated head of bed to 30 degree 10:00AM >returned broken 02 saturation monitor and BP apparatus to buddy nurse >elevated head of bed to 30 degree SUMMARY OF CARE/ PATIENT RESPONSE The first day of care for the patient was centered on keeping him well ventilated and wellperfused. Measures like deep breathing, draining, mechevent settings, monitoring RR rate and depth of breathing was Prevalent. The clients pain was also addressed by the nurse. The patients comfort secured. on the second day the nurses assessment was briefly interrupted by 2 note decrease in breath sound and occational sound which was attributed to 2 mucus play after having found

in an attempted suction that only half of the action can be accommodated by the ET. Te problem was addressed by nebullization and instillation of sterile water to suctioning. comfort measure can also performed another recurrent problem of the client is his agitation. the client is complaining difficulty of breathing but after checking the mechevent, its tubes. The ET for (secretion) as well as the 02 saturation, I found out that nothing is wrong with them. in fact client 5202 was at 100%.the problem it seemed was more of anxiety on the part of the patient because if someone stay in his side, his breathing returns to normal. Because of this one of the interventions was to accompany the client in times of anxiety. I also re explained/ re informed what the fellow on duty and nurse on duty told him about mechanical ventilators purpose. Comfort measures were also done. On the third day the nursing interventions of the nurse were focused on addressing in effective airway clearance of the clients by having timely suctioning CPPT turning and deep breathing again his anxiety regarding his mechanical ventilator was re assessed and addressed using the same techniques that work previously on him. Pain was also addressed by administering PRN pain medication. Comfort at the patient was ensured by keeping him in neutral position putting on elastic bandage. Antiembolic stockings and elevating extremities. This also increases perfusion of peripleries and decreases edema of patient. What is notable for the client on the 4th day is his big leap from mechvent to room air. Again the focus of my intervention centered on the clients mobilization of secretions as he is still not be able to expectorale. I thought him coughing techniques and suctioned oral secretions. CPPT turning and hydration were also performed. On the last day of duty, the nurse attempted to again convince the client to sip water ordered. It was very much appreciated by the nurse when the patient agreed to do so, not once but twice. Next the patient also learned how to cough effectively during one of our cough coaching sessions. He was able to expectorate yellow light brown sputum in moderate amount. The nurse also noticed that the patient is more calm and less agitated today despite the fact that his sertraline was deferred by the doctor. EVALUATION of CARE Probably among the strong points of my nursing care is that I was able to establish a good nurse patient report. By the end of my duty, I am able understand my patient better and on anticipate his needs. I was able to improve the way I manage my time and activities in such a way that I can be more efficient without compromising quality of care. With regards to interaction I believe that with time and the increased frequency of having performed a certain procedure, I was able to gain confidence in performing them. This is the words when I first experienced now to inject insulin the first where I got to operate and trouble shoot 2 mechanical ventilator. H is also the first time that I have encountered a patient who is anxious and demanding at the same time and I believe with time, I was able manage even the patients behavior.

With regards to my patient, I am quite happy that his weaning is doing well and that he is soon to be transferred to the ward where he can be with his family. In truth, I believe I will miss tatay Ernesto and our sessions of dealing with his anxiety As to the improvement of my care, I believe that being more certain of rationals and reading recall of previous lessons would still improve my performance. I could also use one of my previous as if its not documented ADDITIONAL EVALUATION of STAFF Although I have previously evaluated the staff I would like to re evaluate again because I noticed some change in them. Last week I noticed that not all of them seem to trust us enough to let us perform our nursing care by ourselves but this week I noticed that they would leave me at the bed side and only ask for upgrades occasionally. I believed that after our two week duty our relationship with the staff has improved.