MIAMI DADE COLLEGE - MEDICAL CENTER CAMPUS - SCHOOL OF NURSING

NUR 1025L: Fundamentals Nursing Clinical

Students Name: Francisco J Ortiz Date: _06/08/13_ Clients Initials: ____IH____ Admission Date: _04/01/13_
Age: ___91___Yr_____Mo DOB: ______08/28/1921_____ Sex: Male X Female Race/Ethnicity: White/______________
Support System: ______son_________________________________________________________ Religion: _Catholic__________
MEDICAL HISTORY
ALLERGIES: _____NKA__________________________________________________________________________________________
Admitting Medical Diagnosis (es): _____DMII; Fracture of humerus; dementia; hypertension; lipoid metabolic disorder, iron deficiency;
anemia___________________________________________
_________________________________________________________________________________________________________________________________________
Chief Complaint:
______Abnormal lab______________________________________________________________________________________________

History of Present Illness: Pt from nursing home history of GI bleeding. Pt was sent back to the hospital because of low
HH__________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
Past Medical History (include past surgical history ): __Significant for hypertension, diabetes , dementia and
hyperlipidemia_________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________

Clients
(Parents)Understanding
of
Illness:
________Pt
has
dementia
and
cannot
recollect
information
given____________________________________________________________________
__________________________________________________________________________________________________________________
Stage of Development: Erickson Ego Integrity vs. Despair ___ Freud According to Freud, the genital stage lasts throughout adulthood. He
believed the goal is to develop a balance between all areas of life. Piaget _ Formal Operational
____
Special Developmental Considerations: ________________________________________________________________________________
Height:
_____54________
Weight:
____110lb___________
Placement
in
Growth
Chart:
_____________________________________________
Immunizations: ___________________________________________________________________________________________________
VITAL SIGNS
Time Taken: _______________ Activity: ______________ Position: ____wheel chair__________
T_36.4____ P__96__ R 19__ BP _129/68___ Baseline (Normal Age for Age): T_ 36.137.8 P_60 -100 R_12-20_ BP 120/80 _
NUTRITION
Diet: ______________________________ Food Preferences: ______________________________________________________________
1

Nutritional Requirements: (Cal/Kg/Day): _____________________________Total Calories per Day: _____________________________

Fluid Requirements (Ml/Kg/Day): __________________________________ _Total Fluids per Day: _______________________________
Special Treatments: ___________________________________________________________________________________________________________

__________________________________________________________________________________________________________________
Medications at Home:_N/A___________________________________________________________________________________________
__________________________________________________________________________________________________________________

Medication(s) Worksheet
NAME
CLASSIFICATION

DOSE/ROUTE/FREQUENCY
SAFE RANGE

Prilosec

20mg daily by mouth

MECHANISM
OF ACTION

INDICATIONS

Binds to an
enzyme on
gastric
parietal cells
in the
presence of
acidic
gastric pH,
preventing
the final
transport of
hydrogen
ions into the
gastric
lumen.

GERD/maintena
nce of healing
in erosive
esopha- gitis.
Duodenal
ulcers (with or
without antiinfec- tives for
Helicobacter
pylori). Shortterm treatment of active
benign gastric
ulcer.
Pathologic
hypersecretory
conditions,
including
Zollinger-Ellison syndrome.
Reduction of
risk of GI
bleeding in
critically ill
patients.

SIDE EFFECTS

NURSING CONSIDERATIONS
AND PATIENT EDUCATION

A Assess patient
CNS:
routinely for
dizziness,
epigastricor abdominal
drowsiness,
pain and frank or
fatigue,
occult blood in the
headache,
stool, emesis, or
weakness.
gastric aspirate.
CV: chest
pain. GI:
Monitor CBC with
abdominal
differential periodically
pain, acid
during therapy.
regurgitatio
n,
constipation
, diarrhea,
flatu- lence,
nausea,
vomiting.
Derm:
itching,
rash. Misc:
allergic
reactions.

Norvasc

10mg 1 tab PO

Inhibits the
transport of
calcium into
myocardial
and vascular
smooth
muscle cells,
resulting in
in- hibition
of excitationcontraction
coupling and
subsequent
contraction.

Indications:Alone
or with other
agents in the
management of
hypertension,
angina pectoris,
and vasospastic
(Prinzmetals)
angina.

CNS:
headache,
dizziness,
fatigue. CV:
peripheral
edema,
angina,
bradycardia
,
hypotension
, palpitations. GI:
gingival
hyperplasia,
nausea.
Derm:
flushing.

Monitor blood pressure

and pulse before therapy,
during dose titration, and
periodically during
therapy. Monitor ECG
periodically duing
prolonged therapy.

Celexa

Namenda

10mg 1 tab PO

10mg 1 tab PO

Selectively
inhibits the
reuptake of
serotonin in
the CNS.

Depression.

Binds to
CNS Nmethyl-Daspartate
(NMDA) receptor sites,
preventing
binding of
glutamate,
an excitatory
neurotransm
itter.

Moderate to
severe
Alzheimers
dementia.

CNS:
NEUROLEPTIC
MALIGNANT
SYNDROME,
SUICIDAL
THOUGHTS,

apathy,
confusion,
drowsiness,
insomnia,
weakness,
agitation,
amnesia,
anxiety.

CNS:
dizziness,
fatigue,
headache,
sedation.
CV:
hypertensio
n. Derm:
rash. GI:
weight gain.
GU: urinary
frequency.
Hemat:
anemia.

Assess for suicidal

tendencies, especially
during early therapy and
dose changes. Restrict
amount of drug available
to patient. Risk may be
increased in children,
adolescents, and may
minimize dry mouth. If
dry mouth persists for
more than 2 wk, consult
health care professional
regarding use of saliva
substitute

Assess cognitive function

(memory, attention,
reasoning, language,
ability to perform simple
tasks) periodically during
therapy.

Amaryl

4mg 1 tab PO (with

breakfast)

Lower blood
glucose by
stimulating
the release
of insulin
from the
pancreas
and
increasing
the
sensitivity to
insulin at
receptor
sites. May
also decrease
hepatic
glucose
production.

Control of
blood glucose
in type 2
diabetes
mellitus when
diet therapy
fails. Require
some
pancreatic
function.

CNS:
dizziness,
drowsiness,
headache,
weakness.
GI:
constipation
, cramps,
diarrhea,
druginduced
hepatitis,
heartburn, q
appetite,
nausea,
vomit- ing.
Derm:
photosensiti
vity, rashes.

Observe for signs and

symptoms of
hypoglycemic reactions
(sweating, hunger,
weakness, dizziness,
tremor, tachycardia,
anxiety).

Medication(s) Worksheet
CLASSIFICATION
NAME

DOSE/ROUTE/FREQUENCY
SAFE RANGE

MECHANISM
OF ACTION

INDICATIONS

SIDE EFFECTS

NURSING CONSIDERATIONS
AND PATIENT EDUCATION

Zestril

10mg 1 tab PO

ACE
inhibitors
block the
conversion
of
angiotensin
I to the
vasoconstric
tor
angiotensin
II. ACE
inhibitors
also prevent
the
degradation
of
bradykinin
and other
vasodilatory
prostaglandi
ns. ACE
inhibitors
also q
plasma
renin levels
and paldosterone
levels. Net
result is
systemic
vasodilation.

Alone or with
other agents in
the
management of
hypertension.

CNS:
dizziness,
drowsiness,
fatigue,
headache,
insomnia,
vertigo,
weakness.
Resp:
cough,
dyspnea.
CV:
hypotension,
chest pain,
edema,
tachycardia.
Endo:
hyperuricem
ia

Hypertension: Monitor
bloodpressure and pulse
frequently during initial
dose adjustment and
periodically during
therapy. Notify health
care professional of
significant changes.

Ferrous sulfate

65mg tab with breakfast

An essential
mineral
found in
hemoglobin,
myo- globin,
and many
enzymes.
Enters the
bloodstream and
is
transported
to the
organs of
the reticuloendoth
elial system
(liver,
spleen, bone
marrow),
where it is
separated
out and
becomes
part of iron
stores.

Prevention/treat
ment of irondeficiency
anemia

CNS: IM, IV

SEIZURES,
dizziness,
headache,
syn- cope.
CV: IM, IV
hypotension
,
hypertensio
n,
tachycardia.
GI: nausea;
PO,
constipation,
dark stools,
diarrhea,
epigastric
pain, GI
bleeding;

Assess nutritional status

and dietary history to
determine possible cause
of anemia and need for
patient teaching.
Assess bowel function for
constipation or diarrhea.
Notify health care
professional and use
appropriate nursing
measures should these
oc- cur.

Zocor

20mg 1 tab PO nightly

Inhibit an
enzyme, 3hydroxy-3methylgluta
ryl-coenzyme A
(HMG-CoA)
reductase,
which is
respon- sible
for
catalyzing
an early
step in the
synthesis of
cholesterol.

Adjunctive
management of
primary
hypercholesterolemia and
mixed
dyslipidemias.

10

CNS:
dizziness,
headache,
insomnia,
weakness.
CV: chest
pain,
peripheral
edema.
EENT:
rhinitis;
lovastatin,
blurred
vision.
Resp:
bronchitis.

Obtain a dietary history,

especially with regard to
fat consumption.

Aspirin

81mg daily PO

Inhibits the
synthesis of
prostaglandi
ns that may
serve as
mediators of
pain and
fever,
primarily in
the CNS.
Has no
significant
antiinflammator
y properties
or GI
toxicity.

Mild pain.
Fever.

GI:

HEPATIC
FAILURE,
HEPATOTOXICIT
Y (overdose).

GU: renal
failure (high
doses/chroni
c use). Hemat:
neutropenia,
pancytopeni
a,
leukopenia.
Derm: rash,
urticaria.

11

Assess overall health

status and alcohol usage
before administering
acetaminophen. Patients
who are malnourished or
chronically abuse alcohol
are at higher risk of
developing hepatotoxicity with chronic use
of usual doses of this
drug.
Assess amount,
frequency, and type of
drugs taken in patients
self-medicating,
especially with OTC
drugs. Prolonged use of
acetaminophen increases
the risk of adverse renal
effects. For short-term
use, combined doses of
acetaminophen and
salicylates should not
exceed the recommended
dose of either drug given
alone.

PATHOPHYSIOLOGY-BRIEF TEXTBOOK PICTURE WITH CLIENT COMPARISON

Definition, Etiology, Incidence, Pathophysiology, Diagnostic tests, Signs & symptoms, Medical treatments

Textbook

Client

Pathology- Incidence of anemia reflect the presence of bone

marrow failure or excessive loss of red blood cells or both.
Bone marrow failure can occur due to nutritional
deficiencies, toxic exposures, tumor, or mostly due to
unknown causes. Red blood cells can be lost through
hemorrhage or hemolysis (destruction) in the latter case, the
problem can be caused by the effects of red blood cells that
do not correspond to the resistance of normal red blood cells
or due to several factors outside the red blood cells that
causes red blood cell destruction.
Red blood cell lysis (dissolution) occurs mainly in the
phagocytic system or in the reticuloendothelial system,
especially in the liver and spleen. As a byproduct of this
process the bilirubin that is formed in phagocytes will enter
the bloodstream. Any increase in red blood cell destruction
(hemolysis) immediately reflected by increasing plasma
bilirubin (normal concentration of 1 mg / dl or less; levels of
1.5 mg / dl result in jaundice in the sclera.
Anemia is a blood disease characterized less low levels of
hemoglobin (Hb) and red blood cells (erythrocytes). The
function of the blood is carrying food and oxygen to all
organs of the body. If the supply is less, then the intake of
oxygen will be less. As a result, can inhibit the work of the
vital organs, the brain One. The brain consists of 2.5 billion
bioneuron cells. If capacity is lacking, then the brain will be
like computer memory is weak, slow catch. And if it is
damaged, can not be repaired (Sjaifoellah, 1998).
12

Classification- Anemias can be classified by cytometric

schemes (i.e., those that depend on cell size and hemoglobincontent parameters, such as MCV and MCHC),
erythrokinetic schemes (those that take into account the rates
of rbc production and destruction), and
biochemical/molecular schemes (those that consider the
etiology of the anemia at the molecular level.
Etiology- The most common cause of anemia is deficiency of
nutrients required for the synthesis of red blood cells, such as
iron, vitamin B12 and folic acid. The rest is the result of a
variety of conditions such as hemorrhage, genetic
abnormalities, chronic disease, drug toxicity, and so on.
Statistics7% of children aged 1-2 had anemia in the US 1999-2000
(MMWR, NCHS, CDC)
12% of women aged 12-49 had anemia in the US 19992000 (MMWR, NCHS, CDC)
174,600 nursing home residents had anemia in the US
1999 (National Nursing Home Survey, NCHS, CDC)
10.7% of nursing home residents had anemia in the US
1999 (National Nursing Home Survey, NCHS, CDC)
3.4 million cases in the US (Mayo Clinic)
1.3% of population self-reported having anemia in
Australia 2001 (ABS 2001 National Health Survey,
Australias Health 2004, AIHW)
0.3% of male population self-reported having anemia in
Australia 2001 (ABS 2001 National Health Survey,
Australias Health 2004, AIHW)
2.3% of female population self-reported having anemia in
Australia 2001 (ABS 2001 National Health Survey,
Australias Health 2004, AIHW)
217,000 women self-reported having anemia in Australia
2001 (ABS 2001 National Health Survey, Australias Health
2004, AIHW)
13

DIAGNOSTIC TESTS

14

Test

RESULTS

(i.e. X-Ray, MRI, EEG, EKG)

Date, Result, Significance

15

Laboratory values
CHEMISTRY
PROFILE

NORMAL
VALUES

CLIENTS VALUES
DATE

DATE

HEMOTOLOGY

NORMAL
VALUES

DATE

CLIENTS VALUES
DATE

SODIUM

135-145
Meq/L

142
2/21/13

WBC

3.8-10.8
K/uL

4.822/21/13

POTASSIUM

3.5- 5.1
mEq/L
98-108
mEq/L

4.5
2/21/13

RBC

3.80-5.20

2.06*
2/21/13

109
2/21/13

HGB

11.8-15.4g/dl

CO2

19-34

HCT

CALCIUM

8.2-10.3
mg/dL
70-105
mg/dL

23.0
2/21/13
7.7
2/21/13
261
2/21/13

MCH

36.0*
2/21/13
1.35*
2/21/13

CHLORIDE

GLUCOSE

BUN

7-25 mg/ Dl

CREATININE

0.6-1.2
mg/dL

PHOSPHORUS
CHOLESTEROL
TOTAL PROTEIN

6.4-8.9 g/dL

ALBUMIN

3.5-5.0 g/dL

ALBUMIN/GLOBULI
N RATIO
AST (SGOT)
ALT (SGPT)
TOTAL BILIRUBIN
AMYLASE
LIPASE

13-39 U/L
7-52 U/L
0.3-1.0
mg/dL

6.4
2/21/13
3.48
2/21/13
2.92
2/21/13
23 2/21/13
15 2/21/13

MCV

79.4-94.8fL

90.7
2/21/13

MCHC

25.6-32.2 pg

PLATELETS

11.5-15.0%

27.8
2/21/13
16.6
2/21/13

DIFFERENTIAL
NEUTROPHILS
SEGMENTS
BANDS
LYMPHOCYTES
EOSINOPHILS
BASOPHILS
MONOCYTES
COAGULATION STUDIES
PTT

16

DATE

DATE

SODIUM

135-145
Meq/L

142
2/21/13

WBC

3.8-10.8 K/uL

4.82
2/21/13

POTASSIUM

3.5- 5.5
mEq/L
98-108
mEq/L

4.5
2/21/13

RBC

3.80-5.20

2.05*
2/21/13

109*
2/21/13

HGB

11.8-15.4g/dl

CO2

19-34

HCT

CALCIUM

8.2-10.3
mg/dL
70-105
mg/dL

23.0
2/21/13
7.7*
2/21/13
261*
2/21/13

MCH

36.0*
2/21/13

MCHC

CHLORIDE

GLUCOSE

BUN

7-25 mg/ Dl

MCV

CBC

WBC

Hgb
Hct

BMP

Plts

Na
K

Cl

HCO3

BUN

Glucose
Creatinine

17

URINALYSIS
COLOR
APPEARANCE
SP. GRAVITY
1.010-1.025
PH
4.5-8.0

TEST

MISCELLANEOUS TEST
NORMAL
CLIENTS VALUES
VALUES
DATE
DATE
DATE

GLUCOSE
KETONE
OCCULT BLOOD
PROTEIN
BILRUBIN
UROBILINOGEN
NITRITE
LEUCOCYTE
CAST
WBC
RBC
CRYSTALS
SQUAMOUSCELLS/
EPITHELIAL
CELLS

Relate the clinical significance of abnormal lab values above:

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
______________________________________________________

Head to Toe Assessment

General Appearance:
The pt is resting comfortably in no acute distress
18

Head & Hair: Norm cephalic and atraumatic

Face: Norm cephalic and atraumatic
Eyes: Norm cephalic and atraumatic
Ears: Norm cephalic and atraumatic
Nose: Turbinates bright red and swollen, mucous pink, no swelling
Lips/Mouth/Throat:
No cracking/ lesions on lips, mouth is clean and free from debris, mild breath odor.
Neck:
Chest/Breast:
Clear to palpation and auscultation lateral chest is larger than anterior/posterior diameter.
Lungs:
Clear to auscultation; no abnormal sounds heard.
Heart:
Normal rhythm sounds heart at the fine precordial points.
Abdomen/Kidneys:
Normal bowel sounds, no masses, lumps, or tenderness found.
Genitalia (Internal Exam Deferred): N/A
Rectum (Internal Exam Deferred): N/A
Extremities:
No edema clubbing or cyanosis
Back: no deformities
R.O.M.: Limited range of motion. Patient is in the wheelchair bound.
Document findings on next page

19

20

Plan of Care
Priority Nursing Diagnosis:
Risk Nursing Diagnosis: Risk for infection related to abnormal labs
Supporting Data:
Subjective: Patient states I am tired
Objective: Labs show abnormal labs
Expected Outcome (Goals)
Long Term:
Short Term:
Nursing Interventions
Nursing Actions

Scientific Principle
and/or Rationale

Evaluation

Modification of Plan of
Care

21

CARE PLAN RUBRIC

Student: ___________________________________
Date: ______________________
CATEGORIES
SUBJECTIVE DATA
(Relevant and timely and quoted
from patient)

POSSIBLE
POINTS
10

YOUR
POINTS

22

COMMENTS

OBJECTIVE DATA
(Includes vital signs, physical
assessment findings, diagnostic
tests and procedures, relevant
medications, etc.)
NURSING DIAGNOSIS
(NANDA, R/T, AEB)

10

GOAL
(Condition, Time Frame,
Parameters, and must be realistic)

20

INTERVENTIONS AND
RATIONALES
(Assess, Assist, and Teach)

20

EVALUATION OF CARE PLAN

(Evaluate each nursing action for
effectiveness)

10

MODIFICATION OF CARE PLAN

(Modify patient care plan based on
patients response to interventions)

10

20

*TOTAL SCORE:
*Student must obtain score of > 77% in order to obtain a grade of S on the weekly care plan.
Reviewed with student: ______________________________
23

Date: ___________________

Signature

24

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