Professional Documents
Culture Documents
School of Nursing
N4810 Adult Health Nursing II Clinical
3 units
DIRECTIONS FOR COMPLETING THE CLINICAL PLAN OF CARE
The Clinical Preparation Form is considered homework in which the student prepares to give nursing care
by first reviewing pertinent aspects of patient care specific to the patient selected during the clinical
experience. The worksheet must be completed prior to the beginning of the clinical learning experience.
There are a number of sections to this worksheet and each section is to be completed. The following are
the directions for completing the worksheet. If you have any questions about completing the worksheet
or regarding instructor comments on you work, please contact your clinical instructor as soon as possible.
Submit electronically, unless specified otherwise by your clinical instructor.
Student/Date: Include your full name and the date of the clinical experience
Patient Initials/Medical Record Number/Ethnic or Cultural Background: Do not use the name of the
patient, use only the patient's initials and medical record number. Don't forget to include information
about your patient's cultural background.
Admission Date: Identify the date of admission to the hospital.
Admitting Diagnosis: Identify the admitting diagnoses of the patient.
Other Diagnosis/Surgical Procedures: Look on the H&P, the admitting note, the nursing history and the
operative note. If applicable identify all medical diagnosis and surgical procedures done currently or in
the past.
Allergies: Note specific allergies. If none, write "none" or NKDA"
Diet: Identify the specific diet for patient
Intake and Output (I & O): Indicate if the patient is on I & O includes all pts. receiving IV therapy
IV: Indicate the type and location of IV, type of solution and the rate per hour.
Invasive Tubes: Indicate any invasive tubes that are present.
Pertinent Laboratory & Diagnostic Information: Identify the date of the lab work, low or high values
accompanied by arrows up or down to demonstrate the trend.
Medications: Identify the name of the drug, both generic and trade, mechanism of action, side effects,
rationale, and nursing implication and patient teaching. This should be done for every medication the
patient is receiving. Use your drug book.
Patient Care Plan: Review the pt. care plan for accuracy and thoroughness. Make any changes you feel
are appropriate. For example, add a problem which you feel needs to be included. Describe the expected
outcome and the appropriate nursing interventions.
Ethnicity:
Admitting Diagnosis: Endocarditis of mitral valve Vital Signs: Temp: 36.2 HR 90 RR 20 BP: 156/92 O2 Sat: 94 Pain Scale & Scale Type: Denies
Pain, Adult number scale.
History related to this admission: Pt transferred from Los Banos on 11/6/14. Presented with shortness of breath and respiratory distress. Pt was
hypoxic. However, husband refused intubation. Pt was placed on BiPAP and showed improvement. BP was in the 180s. Gave sublingual
Nitroglycerin. BP dropped in the 80s. Gave 3 IV fluids. Still remained hypotensive with systolic BP in the 80s. Pt. had previous multiple
hospitalizations due to bacteremia. Now has diarrhea.
Hospital Problem list: IV drug abuse, Hypothyroidism, HTN, Respiratory failure, PNA, Sepsis, Lactic Acid, Hypotension, Acute Encephalopathy,
Acute diarrhea, Acute on chronic respiratory failure, COPD.
Past Medical History: Chronic Airway obstruction unspecified essential HTN, Asthma, Sepsis, Hypothyroidism, HTN, Leukocytosis, and Hepatitis.
Admit Date: 11/6/14 POD: N/A
Surgical History & Date: Hysterectomy, Liver tumor removed. MD(s): Tesfaye, B.
Non Hospital Problem: UTI, Sepsis, Staphylococcus aureus bacteremia, Cerebral ischemia, Acute encephalopathy, Leukocytosis, Acute renal
failure w/hypoxia, Pneumonia, Hypernatremia, Endocarditis, Anemia, CVA, NSTEMI, Hypotension, Hypomagnesaemia, Diarrhea, Fluid overload,
Mitral valve regurgitation.
Diet : Regular
Activity: Ambulate w/1 person assist
Foley : None Feeding Tube & Rate: None
Advance Directive: Yes ________ No ___X___
Drains/ Tubes: None
Isolation : contact for c-diff VS Freq: Q4HR
Glucose Monitoring: None DVT Prophylaxis : SCD while resting; Lovenox
Vascular Access: Central line IJ triple lumen
PCA/Epidural: None Telemetry & Rhythm: continuous, NSR
IV Site: N/A IV Solution & Rate: N/A
Safety Considerations: Side rails, Fall precautions. Restraints: None
IV Site: N/A IV Solution & Rate: N/A Labs for day of clinical: 11/12/14Vancomycin trough 30 minutes prior to 1600 dose; Potassium Routine PRN
2 hours after replacement complete,11/12/14: Basic Metabolic Panel w/GFR; CBC w/ Automated Differential
Dressing Changes & Frequency: PICC line Q7days
Scheduled Procedures: Repair of tricuspid and mitral value on 11/15/2014
Procedures done this admission: EKG, CT Chest, Heart Catheterization, Echocardiograms, NIVL, and NM
Oxygen: Room air
Respiratory Treatment: Ipratropium/ Albuterol (Duoneb) 0.5mg/2.5mg/3mL Nebsoln Q4H PRN
Vent Settings: BiPAP ventilator non- invasive. Ipap:12; Epap: 8; Pressure support: 4; Set rate: 10; Tidal volume:156; Minute ventilation: 10.
Advanced Hemodynamic Monitoring & Values: None
IV Drips Medications Dosage & Rate: None
Medication
Generic & Trade Name
Dose, Route, Frequency
Atorvastatin (Lipitor)
Tab 10 mg oral daily.
Clonazepam (Klonopin)
Tab 0.5 mg Oral BID
Enoxaparin (Lovenox)
Inj 40 mg Subcut Q12 H
Famotidine (Pepcid)
20 mg oral BID
Fluticasone/Salmeterol
(Advair Diskus)
250mcg/50 mcg oral
inhaler 1 puff oral BID
Mechanism of Action
Classification
Lipid-lowering agents.
Lowers total and LDL
cholesterol and triglycerides.
Increases HDL cholesterol.
Slows the progression of
coronary atherosclerosis
decreasing coronary heart
diseaserelated events.
Benzodiazepine produces
sedative effects in the CNS.
Patient-Specific Rationale
Nursing Considerations
(Assessment implications, side effects, reasons to hold med,
administration rate, etc)
Moderate bilateral
plaguing in carotid artery
showed on NIVL Duplex
Scan Extra cranial
Bilateral.
Furosemide (Lasix)
40 mg oral BID
Ipratropium/ Albuterol
(Duoneb)
0.5mg/2.5mg/3mL
Nebsoln Q4H PRN
Labetalol
(Normodyne/Trandate)
Inj 10 mg Q6H PRN
Antihypertensive - Blocks
stimulation of beta1
(myocardial)- and beta2
(pulmonary, vascular, and
uterine)-adrenergic receptor
sites.
Lactobacillus Acidophilus
(Floranex, Probiata)
Tab TID
Maintains an acidic
environment in the body to
prevent growth of harmful
bacteria.
Hormones replacement in
hypothyroidism to restore
normal hormonal balance
Levothyroxine
Tab 50 mcg. Oral Daily. 1
hr before bkfst
Lisinopril
(prinvil, Zestril)
Tab 10 mg oral daily
Antihypertensive lowering
of BP in hypertensive
patients
Lorazepam (Ativan)
0.5 mg Q4H PRN
Anti-anxiety: potentiating
GABA to decrease anxiety
Magnesium Oxide
(Magox)
Tab 400 mg TID w/meals.
Metoprolol Tartrate
(Lopressor)
Tab 12.5 mg oral BID
Anti-hypertensive - Blocks
stimulation of beta1
(myocardial)-adrenergic
receptors. Does not usually
affect beta2 (pulmonary,
vascular, uterine)-adrenergic
receptor sites.
Anti-infective - Disrupts
Pt. has endocarditis, C-diff,
DNA and protein synthesis in and Sepsis.
susceptible organisms.
Metronidazole (Flagyl)
500 mg in 0.79 % NaCl
100 mL (Premix) IV Q8H
Nitroglycerin SL
(Nitrostat)
Tab 0.4 mg Sublingual
Q5min PRN
Pt presented with
hypertension upon
admission and has a hx of
hypertension. BP on both
days of clinical stayed
around 150/90s.
Patient experienced severe
anxiety on my shift on both
days.
Pt. has hx of
hypomagnesaemia and has
diarrhea that may cause
loss of electrolytes. Pt. is
also getting Lasix that
might further aid this loss.
Pt. presented with
hypertension. Also patient
has pericardial effusion
that increases the workload
of the heart; thus this med
can decrease the workload.
Ondansetron (Zofran)
2mg/mL Inj 4 mg Q6H
PRN
PRN Sleep
Tiotropium (Spiriva)
Dose 1 cap oral inhalation
Daily
Bronchodilator - Acts as
Pt. has respiratory failure
anticholinergic by selectively and pneumonia
and reversibly inhibiting M3
receptors in smooth muscle
of airways.
Vancomycin (Vancocin)
50 mg/mL Oral Soln
Compounded 250 mg oral
Q6H
Vancomycin 650 mg in
Nacl 0.9% 150 mL IV
Q12H
See above
See above
LABORATORY DATA
LABS
Normal Range
(Fill in Hospital Norms)
MEDICATION WORKSHEET
RESULT 1
(11/9/11 @0400)
RESULT 2
RESULT 3
(11/11/14
@0235)
CBC
WBC
4-11
11.8
12.8 H
RBC
3.9-4.67
3.28
3.54- L
Hemoglobin
13-18
9.4
10.5- L
Hematocrit
40-52
30.5
32.9- L
80-100
27-33
31-36
<16.4
93
28.7
30.8
20.3
93
29.7
31.9
20.8-H
150-400
182
202
49-74
87-H
73
26-46
17-L
Low levels of
lymphocyte could be
due to sepsis and
radiation therapy. Pt had
a hx of liver tumor.
2-12
10
136-145
3.5-5.1
98- 107
142
4.6
115
144
4.0
114- H
70-100
136
118
MCV
MCH
MCHC
RDW
PLT COUNT
WBC DIFF
NEUTROPHIL %
BANDS %
LYMPHOCYTE%
MONOCYTE %
CHEMISTRY
Sodium
Potassium
Chloride
CO2(bicarb)venous
Glucose
RDW is an indication of
the variation in RBC
size. Elevated levels
could be due to anemia
as RBC fragmentation
alters RBC size and
shape.
glycogen stores,
gluconeogenesis, and
the subsequent
production of glucose.
They could also be
elevated d/t acute renal
failure and diuretic
therapy.
Calcium
phosphorus
Magnesium
HDL
LDL
Cholesterol
Triglycerides
BUN
8.2-10.2
7.7
8.0
1.8- 2.4
2.3
1.8
6-25
27
25
Creatinine
Vanco Trough
LIVER PANEL
Total protein
Albumin
0.4-0.8
10-20
0.54
6.4-8.2
3.2-4.7
0.62
19.8
11/8 0140
6.1
2.2
Bilirubin Total
Alk phosphatase
AST
0-1.1
26-137
0-37
0.7
63
108
ALT
0-60
100
Lipase
Amylase
Ammonia
Lactate
Serum Ketones
CARDIAC PANEL
CPK
Albumin is synthesized
in the liver. Low
albumin could be d/t hx
of smoking, liver tumor,
hepatitis, cirrhosis and
acute renal failure.
Elevated levels indicate
liver dysfunction. Pt has
a hx of smoking, liver
tumor, cirrhosis, and
hepatitis.
Elevated levels indicate
liver dysfunction. Pt has
a hx of smoking, liver
tumor, cirrhosis, and
hepatitis.
CPK-MB
Troponin
Myoglobin
BNP
COAGULATTION
PT
0-0.05
0.03
12.1 15.3
11/6 0750
16.4
INR ratio
PTT
Fibrin level
Bleeding time
D-Dimer
UA collection type
Urine color
0.9-1.1
1.4
Yellow
Unknown
Amber
Urine appearance
Clear
SI cloudy
Specific gravity
Urine Ph
Urine glucose
1.005-1.030
4.6- 8.0
Neg
1.018
5
Trace
Urine bilirubin
Urine blood
Neg
Neg
Neg
Large
Urine Ketones
Neg
Trace
Urine Nitrites
Urine Protein
None
None
Neg
100
Urine Leukocytes
URINE MICRO
WBC HPF
RBC HPF
None
Neg
0-5
0-2
3
20
none
None
None
none
Nitrate HPF
Epithelial
Bacteria
Mucous
URINE CULTURE
CSF
WBC
RBC
Glucose
Protein
Culture
Normally, no ketones
are present in the urine;
however, a patient with
poorly controlled
hyperglycemia may
have massive fatty acid
catabolism. The purpose
of this catabolism is to
provide an energy
source when glucose
cannot be transferred
into the cell because of
insulin insufficiency. Pt.
had high glucose levels
and liver dysfunction
(hx. Of smoking,
hepatitis, cirrhosis, and
liver tumor) that cant
break down the glucose
effectively.
Possible protein in urine
might be an indication
of livers insufficiency
in breaking it down and
kidneys insufficiency in
filtering them (pt. has
acute renal failure).
Presence of blood in
urine could be due to
traumatic catheterization
(removed catheter on
11/10) and liver
dysfunction.
No growth as
of 11/11
C-diff Toxin
MRSA - Neg
11/ 6 2046
pH
PO2
PCO2
7.35-7.45
80-100
35-45
7.399
96
26.5
Bicarbonate
22-26
16
Oxygen Saturation
Anion gap
Lactate
95-100
97
0.4-2.0
3.2
DIAGNOSTIC DATA
____________________
ECG 11/14/14
11/6/14 - X ray chest portable
ABGs = Metabolic
acidosis compensated
Decreased pco2 occurs
with hyperventilation.
Following factors could
have contributed for
patient hyperventilating:
respiratory distress
(SOB and increased
WOB), anxiety, and
pain.
Decreased HCo3 levels
could be d/t pt. having
diarrhea and acute renal
failure.
With normal oxygen,
glucose is metabolized
to CO2 and H2O for
energy. When oxygen to
the tissues is
diminished, anaerobic
metabolism of glucose
occurs, and lactate
(lactic acid) is formed
instead of CO2 and H2O.
To compound the
problem of lactic acid
buildup, when the liver
is hypoxic, it fails to
clear the lactic acid.
Pt. has hx of smoking,
liver tumor, cirrhosis,
and hepatitis.
Student Name:
Normal sinus rhythm w/ one PVC
Indication: central line placement. No
pneumothorax
Normal LV size and systolic function.
Left atrial enlargement.
Mild mitral regurgitation with normal PA pressure.
Mitral valve is calcified.
Moderate to severe tricuspid regurgitation
Severe anteriorly directed mitral regurgitation.
Possible old focal calcified vegetation on atrial
surface on posterior mitral valve.
Moderate tricuspid regurgitation.
Mild aortic regurgitation.
No evidence of clot in cardiac chambers.
New large pericardial effusion.
Hepatic cirrhosis.
Mild nonspecific mediastinal and upper abdominal
lymphadenopathy, stable.
Moderate bilateral plaguing. No evidence of
hemodynamically significant disease.
Low probability of PE. Airway disease
predominantly in left lung
Normal coronary angiogram.
Severe mitral regurgitation.
Normal LV function with ejection fraction 60%.
Mild pulmonary HTN.
4. Anxiety
Data to support: pt. had several periods of anxiety
throughout the shift, she got anxious about having
loose stool and not being able to have the surgery
(tricuspid and mitral valve repairmen) on 11/15/14.
Also, she got anxious about getting subcutaneous
shot. When she gets anxious, she gets SOB,
increased WOB, increased BP (156/92), restless,
Interventions:
- Klonopin, Tamezapam, and Ativan
- Encourage pursued lip breathing.
- Answer any questions that might be causing the
anxiety.
- Assess the client's level of anxiety and physical
reactions to anxiety (e.g., tachycardia, tachypnea,
nonverbal expressions of anxiety)
- Provide back rub/massage to relieve anxiety.
- Distract when performing invasive procedure
(Subcutaneous shots)
Problem Evaluation
Problem #
1
Professional Demeanor
Communication/rapport
Technical skills
Organized
Well-prepared
Comprehensive Assessment
Flexible
Coordinator of Care
Team Player
Educator
Ability to Prioritize
Knowledgeable
Instructor Comments:
Date:____________
Irregular
Irregular
Atrial Rate____________________
PR interval ___________________
QT interval____________________
Is AV conduction normal? (Y/N)______________ If not, why is it abnormal?
________________________________________________________________________
P wave normal? (Y/N) ________
or
ventricular
Interpretation of rhythm:
________________________________________________________________________
Potential hemodynamic consequences of this rhythm and interventions for this rhythm:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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.
2.
3.
Lab Diagnostics
a. Test
b. Results
c. Implications & Teaching
4.
5.
6.
7.
a.
b.
Total Points
_____________/100 = ____%