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Instructions: Use blue ink for day before clinical & red Ink for the clinical day. Get all of this information on the day before clinical, then update it on the day of care.
1.) Date of Care: 01-27-10 2.) Patient Initials: LS
Student Name: DC Collins
3.) Age: 57 (face sheet) 3.) Growth and Development Middle Adulthood – Gen.vs. Stagnation 4.) Sex: M (face sheet) 5.) Admission Date:01-21-10 (face sheet)
6.) Reason for Hospitalization (face sheet): l. large hemothorax - syncope 8.) Surgical Procedures: Date 01-26-10 L. sided video-assisted thoracoscopic evacuation of hemothorax and potential decortication (surg. report not yet available)
7.) Medical Diagnosis: (Present diagnoses, past diagnoses; physician’s History and Physical notes in chart; nursing intake assessment and Kardex) Past: Hypertension, Hypercholesterolemia, Depression, seizure disorder, alcoholism (pt. states two years dry) Recent: Cracked ribs mid-December
Surgical Pathophysiology: Video thoracoscopy is performed in the operating room under general anesthesia. Patients have basic anesthetic monitoring including arterial pressure, electrocardiogram, continuous transcutaneous oxymetry, and end-tidal carbon dioxide tension. To ensure maximal exposure, a double-lumen endotracheal tube is used. After intubation, patients are placed in the appropriate lateral decubitus position. Videothoracoscopic procedures are performed with trocars or ports and usually require three 1- to 2-cm intercostal incisions. When possible, the sites of previously placed chest tube thoracostomies are used. Paraphrased from http://ats.ctsnetjournals.org/cgi/content/full/63/2/327
Primary Medical Dx: left side hydropneumothorax
Pathophysiology (detail on the cause of the primary medical diagnosis): Hydropneumothorax = both Air and Pleural Effusion Pneumothorax: These occur as a result of trauma or pre-existing pulmonary disease (eg TB, malignancy, emphysema, histiocytosis X, interstitial fibrosis). Trauma can allow gas into the pleural space via penetration of the visceral pleura, chest wall, diaphragm, mediastinum or esophagus. Iatrogenic pneumothorax as a result of CVP lines, thoracentesis or mechanical ventilation is not uncommon. However, widespread emphysema is the most common cause of secondary pneumothorax. Other causes of pneumothorax such as asthma, certain interstitial lung diseases, lung carcinoma or abscess are less common. An uncommon cause of pneumothorax is from the accumulation of gas produced by microorganisms in an empyema. Pleural Effusion: Systemic arterial vessels supply both pleural surfaces. Lymphatic vessels from the parietal pleura drain to lymph nodes along the anterior and posterior chest wall, whereas lymphatics from the visceral surface drain to the mediastinal lymph nodes. The pleural space normally contains 0.1-0.2 mL/kg of a colorless alkaline fluid, which has less than 1.5 g/dL of protein. The venous side drains approximately 90% of accumulated fluid in the pleural space, whereas lymphatics absorb the other 10%. Chest-wall and diaphragmatic movements enhance absorption of pleural fluid by the vascular and lymphatic vessels. Excessive filtration of fluid can overwhelm these efficient absorptive mechanisms and lead to the formation of pleural effusion. All signs and symptoms – Highlight those your patient exhibits: Chest pain (from surgery), shortness of breath, tachycardia, tachypnea, cough (mild productive), fatigue, cyanosis, anxiety, restlessness, decreased or absent breath sounds, tracheal shift, mediastinal shift, unequal chest rise, hypotension, pale cool clammy skin, narrowing pulse pressure, hypoxia, hypercapnia, respiratory
acidosis, loss of consciousness 9.) ADVANCE DIRECTIVES (NURSE’S ADMISSION ASSESSMENTS): Living Will: N Power of Attorney: N Do not resuscitate (DNR) order (Kardex): N
10.) LABORATORY DATA: Test Glucose RBC HCT EOS ABS Norms 65-99 4.3-5.7 40-50 0.0-0.5
Reason why it pertains to patient. Indicate with an “L” if low or “H” if high. On Admiss ion 125H 3.26L 36L 0.3 Current Value Date 141H 177H 3.55L 3.6L 35L 35L 0.8H 0.2L Test Albumin Hgb EOS BUN/Creatinine Ratio Norms 3.5-5.0 13.716.7 0-7 7-24 On Admission 2.8L 12.7L 4 11 Current Value Date 2.8L 2.1L 11.9L 12.0L 12H 2L 39H
11.) DIAGNOSTIC TESTS Chest X-ray: 1/22 0951: ↑ l. pleural effusion & heart size at upper limits of norm Chest X-ray: 1/22 1523: Bedside AP CXR – Chest Tube Placement New l. thoracostomy tube placed. l. pleural eff. Slightly ↓ tho still moderate. l. lung aeration also improved, w/persistent l. basal consolidation. May be a tiny l. apical pneumothorax. Chest CT: 1/23/10 1741: Chest CT w/contrast. Follow-up post chest tube placement. Tube in proper position. l.l.lobe atelectasis & small l. sided pleural eff. w/ a displaced l. 9th rib fracture. Minimal atelectasis in r. lung base. Chest CT: 1/25/10 0931: w/o contrast. Tube in proper place. Residual l. pneumothorax 26mm, slightly larger laterally, slightly smaller anteriorly. Atelectasis appears unchanged in size. Small r. pleural eff still present. Mediastinal lymph nodes present, largest medial to main pulm. artery. Displaced l. 9th & 10th rib fractures identified. XR: 1/22 1912: r. tib/fib for r. leg pain. AP & cross table. Mild diffuse osteopenia. Mild patellofemoral osteoarthropathy.
CXR: 1/23/10 0910: Stable position of . thoracotomy tube. Redemonstration of mod. Airspace disease at l.l.lobe. Mod size pleural eff, tho slightly ↓ from last exam. No pneumothorax identified. Heart size normal. CXR: 1/25/10 0754: Tube in proper place. Interval drainage of l. pleural eff. Poor compliance of underlying lung – hydropneumothorax at l.lung base, but no increase in atelectasis. Stable patchy mild consolidation at r. lung base. Mild cardiomegaly. No evidence of l. ventricular failure.
CXR: 1/24/10 0834: Tube in proper place. Persistent opacity l. inferior half of chest obscuring l. hemidiaphragm consistent w/ pleural disease. No pneumothorax. Heart not enlarged. CXR: 1/26/10 0755: Portable AP Chest tube stable. No interval change to l. basilar opacity. No pneumothorax.
CXR: 1/26/10 1028: Tube has been repositioned. Interval decrease in l. pleural eff. No pneumothorax identified. Cardiomegaly unchanged. Diffuse bilat. Interstitial and airspace opacities noted, consistent w/pulm. edema.
13.) ALLERGIES/PAIN 13.) Allergies NKDA (medication administration records): 14.) Where is the pain? l.l. chest (Nurses’ notes) U.R. Leg 15.) TREATMENTS 15.) Treatments (Kardex): l. chest tube What are the treatments for? Relieve hydropneumothorax Nicotine Replacement Patch Relieve smoking withdrawal Turn cough deep breathe Pneumonia prophylaxis Retention Catheter to gravity Prevent urine retention Chest tube at neg. 20 cm wall suction Drain hydropneumothorax Suction D/Cd Incentive Spirometer qh when awake Prevent pneumonia, exercise lungs HoB @ 60 deg. at all times Ease of breathing 16.) Support services (Kardex): --17.) Consultations (Kardex): PT eval and treat as appropriate OT eval and treat as appropriate 18.) DIET/FLUIDS Type of Diet (Kardex): Restrictions (Kardex): Gag reflex intact NPO Day of Surgery (1/26) until fully awake, then clear liquids remaining day of surgery. Post-op day 1 advance diet as tolerated to Cardiac Low Fat/Cholesterol/Salt Appetite: Good Fair Poor X Breakfast %100 of liquid Lunch% 25 Supper%----- Started on clr liq, advanced as above for lunch What types of foods are included in this diet and what foods should be avoided? See Above Low fat, cholesterol, salt foods allowed Fluid Intake: (Oral & IV) NPO day shift 24 hours 600 mL Tube Feedings: Type and Rate (Kardex) 300 ml postop (arrived from PACU 1310) thru day shift Check Those Programs That Apply: 14.) When was the last pain medication given? PCA Dilaudid q8min prn. Actively used. D/C’d PCA Mid Shift Percocet 1300 14.) How much pain is the patient in on a scale from 0-10? 8/10 (Nurses’ notes, flow sheet) 0/10 chest, 8/10 U.R. Leg, 10/10 if standing/walking
• • • • •
Problems: Swallowing , Chewing , Dentures (Nurses’ Notes) Needs assistance with feeding (Nurses’ Notes) Nausea or Vomiting (Nurses’ Notes) Overhydrated or dehydrated (evaluate total intake and output on flow sheet) Belching: Other: • Calculate: -300
Is the patient’s intake greater than output? No
19.) INTRAVENOUS FLUIDS (IV Therapy Record) Type and Rate: D5W 10 ml/Hr D5W 10 ml/hr – D/C’d mid shift IV dressing dry: edema: redness: Not Observed LFA near wrist. Dry, no edema or redness. Other: LFA, mid forearm, saline lock. dry, no edema or redness
20.) ELIMINATION Last Bowel Movement: 01/24 01/24 24-hour Urine Output: See #18 above Foley/Condom catheter: 600 Urine + 550 CT drainage = 750 Yes No
Check Those Problems that Apply:
Bowel: constipation X diarrhea flatus incontinence
Urinary: hesitancy frequency burning incontinence odor Other: Type of activity orders: Amb. TID post op day 1 & OOB to chair for all meals. Same Restraints (flow sheet): None None 22.) TPR (flow sheet): 37.6/63/18 96.3/78/20 Use of assistive devices: cane, walker, crutches, prosthesis: None None Weakness: No post op assessment None by end of shift 23.) Height: 175.3 cm --Falls-risk assessment rating: Hendrich II, Score = 4 – High Risk 1, Low Risk Trouble sleeping (Nurses’ Notes): Post op, unknown None Weight: 90.2 kg ---
21.) ACTIVITY (Kardex, flow sheet) Ability to walk (gait): Not ob-served but is post op Antalgic, but well balanced, strong No. of side rails required (flow sheet): None ordered 0 22.) BP (flow sheet): 119/90 97/68 REVIEW OF SYSTEMS
PHYSICAL ASSESSMENT DATA
(Check Nurses’ Notes and shift assessments for the latest information you can get.)
24.) NEUROLOGCIAL STATUS: LOC: alert and oriented to person, place, time (A&O x 3), confused, etc.: A&O x3, drowsy post op A&O x3 – drowsy until mid shift when PCA D/C’d Sensation: 4 extremities Intact x4 Pupils: PERRLA Intact x3 Intact Loss of sensation to touch in upper right leg after PERRLA – 3 mm standing or walking for a couple of minutes 25.) MUSCULOSKELETAL SYSTEM: Bones, joints, muscles (fractures, contractures, arthritis, spinal Muscle Strength: Grips equal curvatures, etc.): Fracture l. ribs 9&10, dx of r. leg mild diffuse Strength 3/5 and equal x3 osteopenia, mild patellofemoral osteoarthropathy Severe pain (10/10), burning, and numbness in upper right leg upon standing or walking for more than a couple of minutes. Motor: ROM x 4 extremities Casts, splint, collar, brace, Walker, W/C, CPM None None 5/5 x4 5/5 x4 26.) CARDIOVASCULAR SYSTEM: Pulses (apical, radial, pedal) (to touch or with Capillary refill (<3s): doppler): Pulses present bilat. radial & dorsalis --Present and strong, apical, radial, and dorsalis <3 Jugular neck vein (distention): Heart Sounds: S1, S2, regular, irregular: No (rate, rhythm, strength) murmur, S3, S4 S1 S2 None S1, S2, No extra sounds Edema, pitting vs. nonpitting: 0 (upper/lower) 0 No edema Any chest pain: Yes, 8/10 – r/t surgery 7/10 before Percocet, 1 after Diaphoresis: No No Nausea: No No Other: --No Speech: Clear, Appropriate Clear, Appropriate Sensory deficits for vision/hearing/taste/smell:--None None
TED hose/plexi-pulses/compression devices: type: None
27.) RESPIRATORY SYSTEM: Depth, rate, Use of Cyanosis: Sputum: color, Cough: productive, Breath sounds: Dim rhythm: Depth accessory No amount: nonproductive: bilat. bases Reg, Rate 20 muscles: --No ----A few rales left side Depth regular, No None observed Mildly productive Dim bilat. Bases, Rate 20 rales bilat bases Use of oxygen / Flow Rate: Oxygen Pulse oximeter: Smoking: *1310 arrived from PACU on 4L NC. *1440 Sats in 70’s – humidification: % oxygen 40+ pack put on mask & ↑ O2 to 6L. --saturation years – still *1450 Sats still ↓ing, incr. O2 to 9L – Sat ↑ to 92% Yes 92% smokes 96% on 6L maskstart of shift. ↓ to 85% off mask mid shift, 92% --↑ 92% using Inc.Spirom., back to 88% off Inc.Spirom. Weaned to 4L late in shift. Off O2 by end of shift. 28.) GASTROINTESTINAL SYSTEM: Abdominal pain, tenderness, guarding; distention, soft, firm: Not observed – pre op pt stated no pain. None Ostomy: describe stoma site and stools: --None 29.) SKIN AND WOUNDS: Color, turgor, Rash, bruises: Describe wounds (size, Edges Type of wound Temp: --location): Chest Tubes left side approximated: drains: WNL Color / None X2 – Not Observed Not Observed --temp approp. CT x2 l. side --None With No tenting Characteristics of Dressings (clean, dry, Sutures, staples, steri-strips, Risk for Other: --drainage: --intact): Intact other: --decubitus ulcer CT Drainage thin, red, CT dressings clean, assessment --non-purulent dry, intact --rating: Braden 19/23 20/23 30.) EYES, EARS, NOSE, THROAT (EENT): Eyes: redness, drainage, edema, ptosis --No redness, drainage, edema, ptosis Ears: --- drainage:--No drainage Nose: redness, drainage edema --No drainage or edema Throat: sore:--Not sore
Bowel sounds x 4 quadrants: + on Ausc Hypoactive after liquid breakfast, absent 1 hr later Other:--None
NG tube: describe drainage: --None
PSYCHOSOCIAL AND CULTURAL ASSESSMENT 34.) Occupation 35.) Emotional None (face state Calm and sheet): Long cooperative Haul Trucker Additional information to obtain from clinical units the night before clinical specific to your patient’s diagnosis: Standardized Pressure ulcer Standardized skin Standardized Clinical Patient education falls-risk assessment: assessment: nursing care pathways materials: assessment: Y Y plans: : Y Y Y Knowledge deficits: Y --- Use of Inc. Spirom Self care deficits: --- --31.) Religious preference --(face sheet): 32.) Marital status S 33.) Healthcare benefits and insurance None (face sheet):
Other Assessment or Treatment Information not include above: Doppler ordered for U.L. Leg – search for thrombi – none observed New Medical Orders: D/C PCA D/C D5W along with the PCA D/C Tele Wean from O2 D/C Suction
Concept Map Boxes, Nursing 212 Student: DC Collins
Include all abnormal data from Database and only from the database. Include all medications and treatments. Identify only problems focused on in Nursing 212. Use only NANDA 2003-2004 diagnoses. Potential for problems cannot be in a box without an actual problem. Knowledge deficits for different areas should be written as separate problems.
Priority: 3 Problem: Acute Pain r/t fluid accumulation in the pleural space and chest trauma, and r/t tissue damage, 2º to surgical incision aeb verbalization of discomfort -Pain level 8/10 reported -Medication delivered via PCA -Chest Tubes -fractured L. 9th & 10th ribs - Mild patellofemoral osteoarthropathy
-Cyclobenzaprine -Ketorolac -Hydromorphone -APAP/Oxycodone
Priority: 1 Problem: Ineffective Breathing Pattern r/t decreased lung expansion and alveolar collapse, 2º to air and fluid in the pleural space aeb dyspnea and difficulty maintaining appropriate O2 saturation -Dx of Pleural Effusion -Pain -Diminished breath sounds at bases -Mild rales left side -CXR / CT: hemothorax, pneumothorax, with alveolar collapse -Mild consolidation at bases -O2 in 70’s at 4L NC, Still ↓ at 6L by mask, and 92% on 9L by mask -Surgical Sedation -Order to TCDB -Order for Incent. Spirom. -HoB ordered to 60 deg at all times -Smoker 40+ pack years -Guaifenesin -Albuterol
Priority: 4 Problem: Risk for Infection r/t surgical incision and ineffective protection, 2º to chest tube placement and VATS, and uncontrolled hemothorax, aeb blood labs and open pathways into the body -High Eosinophil count -Low RBCs -Low Hct -High Eosinophils and Abs. Eosiniphils
Reason For Hospitalization: Left Side Hydropneumothorax / VATS Evacuation of Hemothorax and potential decortication
Priority: 2 Problem: Ineffective Tissue Perfusion: Cardiopulmonary r/t excessive bleeding and decreased cardiac contractility aeb uncontrolled hemothorax and Dx of cardiomegaly -Syncope was cause of ED admission -Glucose 141 -Hct and RBCs Low, replaced by IV Saline
(only highest priority)
O2 Saturation Breathing Pattern Pain
-Low Hgb -Foley -Chest Tubes -Temp of 37.6C
Vitals Wound sites LOC Chest Tube Dressing Most recent K+ labs
-CXR and CT show Cardio-megaly -BP 119/90 -Low Albumin -Triamterene/HCTZ -Nitroglycerine -Atenolol
Connected boxes (if cannot draw connections) : 1: 2: 3: 4:
I don’t know: -Retention Catheter -Nicotine Replacement Patch -Mild diffuse osteopenia -Ondansetron and Promethazine – Relieve N / V -Naloxone – Counter Opioids -Al.Hydroxide/Mg Hydroxide/Simethicone - Heartburn -Diphenhydramine - Itching -Bisacodyl - Constipation
(From Schuster, P.M.: Concept Mapping: A Critical Thinking Approach to Care Planning, 2002, with permission
Concept Map Step 4, 5, NURS 212
Student: DC Collins Patient: LS Room: 7A7-1 Date: 01-27-10 Problem No. 1: Ineffective Breathing Pattern r/t decreased lung expansion and alveolar collapse, 2º to air and fluid in the pleural space aeb dyspnea and difficulty maintaining appropriate O2 saturation General Goal: Effective Breathing Pattern Behavioral Outcome Objective(s)/ Expected Outcome: (use MOSTR) 1. The patient will exhibit self care AEB demonstrating pursed-lip breathing and using the incentive spirometer hourly on the day of care. 2. The patient will demonstrate the ability to breathe comfortably AEB absence of labored breathing and O2 saturation above 92% on the day of care. Nursing Interventions Type of inter- Dele- Patient Responses Include each type: (A) assessment, (T) treatment, vention gate (Evaluation) (E) education, (D) dependent, (I) independent, (C) (A, T, E, D, I, (Y/N) collaboration, (EOC) assess EOCs; Include C, EOC) frequencies for each. List medication names. 1. Demonstrate pursed-lip breathing and explain T,E,I Y Patient said he understood, benefits and tried it several times. 2. Demonstrate use of Incentive Spirometer (IC) T,E,I Y Had an IC on table, but said and explain benefits nobody told him what it was for. He demonstrated use. 3. Assess patient understanding of pursed-lip I, A,EOC N After education, patient breathing and incentive spirometer, and probable demonstrated both level of compliance proficiently with practice. 4. Assess respiratory function, including lung I,A,EOC N No labored breathing. Dim. sounds, for labored breathing, and O2 sats sounds & rales bilat bases. continuously if in distress; qH when O2 Sat is above 92% avg on O2, mid 80’s off 92% mask most of shift. 5. Assess Chest Tube for movement, and for I,A N CT remained in place, suction proper drainage, proper suction, appropriate D/C’d, drainage continued bubbling in chamber 6. Titrate O2 as ordered to increase O2 saturation T,D N *9L by mask beg. of shift above 92% 92%. *6L by mask early in shift 93% *Off O2 for bathing, 85% - IC use brought back up to 92% *4L by mask late in shift 92% *Off O2 by end of shift, low 90’s. Summarize impressions of patient progress toward outcomes, whether they were met, and how the plan should be modified: With education, he learned that he could feel better and have more energy with proper breathing techniques and IC use. Was able to be off O2 long enough to bathe and ambulate by mid shift, and stay off O2, including after ambulation, by end of shift. (Note: this opportunity to see how important patient education is was as useful to me as it was to him)
Problem No. 2: Ineffective Tissue Perfusion: Cardiopulmonary r/t excessive bleeding and decreased cardiac contractility aeb uncontrolled hemothorax and Dx of cardiomegaly General Goal: Improved Tissue Perfusion Behavioral Outcome Objective(s)/ Expected Outcome: (use MOSTR) 1. The patient will demonstrate adequate tissue perfusion AEB palpable peripheral pulses, warm and dry skin, adequate urinary output, absence of respiratory distress, and remaining A&Ox3 on the day of care. 2. The patient will demonstrate knowledge of treatment regimen, including appropriate exercise and medications AEB verbalization of these on the day of care. Nursing Interventions Type of Dele- Patient Responses Include each type: (A) assessment, (T) treatment, intervention gate (Evaluation) (E) education, (D) dependent, (I) independent, (C) (A, T, E, D, I, (Y/N) collaboration, (EOC) assess EOCs; C, EOC) Include frequencies for each. List medication names. 1. Assess pulses, cap refill, and neuro status q2H; A,I,EOC N Pulses strong, cap refill more often if in moderate-severe distress <3 Neuro status intact throughout shift. 2. Keep legs below level of the heart T,I Y Done throughout shift 3. Monitor skin and I&O at least twice per shift A,I Y No cyanosis, I&O remained in balance throughout shift 4. Assess patient knowledge about the implications A,I,EOC N Knows smoking issues. of smoking, proper exercise on the day of care, and Didn’t know about IC use knowledge of medications and procedures being or that movement helps used for his treatment, before education. healing and to prevent clots. Did know about his current meds. 4. Educate patient about effects of smoking on E,I N Wasn’t interested. cardiopulmonary system and offer resources on smoking cessation 5. Educate patient about exercises appropriate for E,I N Had more energy and felt the shift as well as medications and procedures better after use of IC, and again after getting OOB to bathe. Summarize impressions of patient progress toward outcomes, whether they were met, and how the plan should be modified: Perfusion remained good throughout shift with good pulses. Pt voided at least 3 times. Sats dropped to mid 80’s off O2 early in shift, but progressed to being off O2 in low 90’s by end of shift. Breath sounds still remained diminished in bilat bases, and rales were heard in both bases by end of shift, but as the day progressed and he used IC more often, he had more energy and spent more time OOB.
Problem No. 3: Acute Pain r/t fluid accumulation in the pleural space and chest trauma, and r/t tissue damage, 2º to surgical incision aeb verbalization of discomfort General Goal: Reduce Pain Behavioral Outcome Objective(s)/ Expected Outcome: (use MOSTR) 1. The patient will report pain intensity: 0= no pain, 1-3= mild pain, 4-6= moderate pain, 7-9= severe pain, 10= worst pain imaginable, and set goal level at 3/10 or better, AEB verbalization of understanding of scale and goal rating on the day of care. 2. The patient will report that pain management regimes relieve pain AEB report of pain maintained at 3/10 or less on the day of care. Nursing Interventions Type of inter- Dele- Patient Responses Include each type: (A) assessment, (T) treatment, vention gate (Evaluation) (E) education, (D) dependent, (I) independent, (C) (A, T, E, D, I, (Y/N) collaboration, (EOC) assess EOCs; C, EOC) Include frequencies for each. List medication names. 1. Educate patient about pain rating system E, I N Pt. understood scale already 2. Instruct patient about importance of managing E, I N This was new to him, but pain level, as it is easier to manage than to bring he had already been on pain level back down PCA and using it regularly when awake anyway. 3. Educate patient about non-pharmacological pain E, I N Expressed interest in relief methods, including, positioning, slow deep breathing as a way to breathing, muscle relaxation, etc.) control pain. Stated it helped. 4. Have patient describe how unrelieved pain will be E, I N Stated he would continue managed with slow, deep breathing, muscle relaxation, and repositioning himself. 5. Administer pain medication as ordered: T, D N PCA, and later Percocet, PCA Dilauded 0.2 mg q8M (nar- reduced pain in chest to Percocet once PCA D/C’d, once, mid shift. Shift cotic 1-2/10, though it didn’t ended before another dose due s) Y touch the newly reported for U.R. Leg pain non 6. Assess pain level q2h and after meds A, I, EOC N Pain remained low to administered non-existent for chest area (fractured ribs / chest tubes) as long as meds in effect, but nothing helped the leg pain. Summarize impressions of patient progress toward outcomes, whether they were met, and how the plan should be modified: The goal was partially met. The known and expected pains in his chest due to fractured ribs, the presence of the chest tubes, and the hydropneumothorax were well controlled by medications, proper breathing, positioning, etc. But the newly reported leg pain remained uncontrolled across the shift. Recorded the pain levels and symptoms. Pt. also reported these to the physician, PT, and OT.
Problem No. 4: Risk for Infection r/t surgical incision and ineffective protection, 2º to chest tube placement and VATS, and uncontrolled hemothorax General Goal: Absence of Infection Behavioral Outcome Objective(s)/ Expected Outcome: (use MOSTR) 1. The patient will remain free from signs and symptoms of infection AEB by showing no undue redness, warmth, or discharge at the surgical or chest tube sites, and core temperature < 99C on the day of care. 2. The patient will demonstrate appropriate hygienic measures such as hand washing, oral care, and perineal care AEB verbalizing understanding of processes and willingness to perform such care on the day of care. Nursing Interventions Type of Dele- Patient Responses Include each type: (A) assessment, (T) treatment, intervention gate (Evaluation) (E) education, (D) dependent, (I) independent, (C) (A, T, E, D, I, (Y/N) collaboration, (EOC) assess EOCs; C, EOC) Include frequencies for each. List medication names. 1. Assess wound sites, chest tube insertion points, A,I,EOC N Could only assess dressings skin, and core body temperature q2H (not wounds), which remained clean, dry, intact. Temperature remained in the upper 96 deg. F range across shift. 2. Clean wounds and change dressings q2H and/or T,I Y Dressings remained in place as allowed by orders across shift. 3. Assess lung sounds, sputum, pt. use of incentive A,I,EOC N Lung sounds did not worsen. spirometer, skin for moisture and breakdown. No sputum observed. No diaphor-esis. No indication of skin breakdown and found to be low risk. 4. Assess pt. knowledge of and use of appropriate A,I,EOC N Patient well understood hygiene measures before and after instruction hygiene and need to perform it well. 5. Instruct patient where knowledge is deficient E,I N Use of IC was only observed knowledge deficiency. 6. Have patient repeat back and demonstrate these E,I Y After instruction, he used the measures. IC hourly Summarize impressions of patient progress toward outcomes, whether they were met, and how the plan should be modified: Patient maintained a lack of S&S of infection across shift, reduced his risk of pneumonia by beginning use of IC, and demonstrated thorough knowledge of need for good hygiene to prevent infection. His eosinophil count dropped from 12 the previous day to 2 today. (From Schuster, P.M.: Concept Mapping: A Critical Thinking Approach to Care Planning, 2002, with permission
IV Medication Administration / Other Skills Form Nursing 212 student name DC Collins date 01/27/10 I. IV Medication Administration Preparation Complete and show form to instructor before administering the medication. After clearance from your instructor, all parenteral medications must be administered either with a staff RN or LPN or instructor.
Drug name: generic and trade if known Is this order current? Date: Time: Dose Safe? Calculation correct? Why ordered? Allergy to this drug? Primary IV site location: Patent? Date inserted: Type: Size: Length: Secondary IV site present? IV access type Peripheral? Central? PICC? Locked? IV fluid type: IV rate: Side/Adverse effect #1, potential Side/Adverse effect #2, potential Side/Adverse effect #3, potential Side/Adverse effect #4 potential Side/Adverse effect #5, potential Side/Adverse effects, present, include data Should pt. receive drug? Push Medication? Syringe size: Needle size: Filter needed? Administration Rate in minutes: Syringe Pump / Piggyback Medication? Tubing expired? Tubing primed? Administration Rate in minutes: NS Flush Needed? NS Amount: NS Syringe size: Medication #1 D5W Y 01/26/10 1515 Y --IV Maintenance N Left Forearm Y Not Observed Medication #2 Reglan Metocloprami de Y 1/27/10 1300 Y --↑ Gastric Motility N LFA prox to wrist Y 1/21/10 Primary Y – SL distal to elbow Peripheral Medication #3 Medication #4
D5W 10 mL / hr ↑ Serum Glucose
D5W 10 mL / hr Drowsiness Extrapyramid al reactions Restlessness
None Yes 3 mL ----1-2
--3 mL 10 mL
Heparin Flush needed? Heparin Flush Units: Heparin Flush Syringe size: Give medication. Procedure Observed/Assisted by:
MEDICATION RESEARCH, Nursing 212
Instructions: Complete this form for all medications on assigned patient including PRN, all IV solutions and additives. Bring a drug reference to clinical. For TPN, list each major component on a separate line, with additional data listed separately. Reactions may be transposed to cards or reused from a file. Student: DC Collins Patient Name: LS Room: 7A7-01 Date: 01/27/09
Medication name (trade/generic) Drug dose, route & frequency APAP/Oxycodone 325/5 mg tab 1-2 tab PO Q4H PRN (Percocet) Al. Hydroxide / Mg. Hydroxide / Simeth-icone Suspension 30 ml PO Daily PRN Albuterol SVN 2.5 mg/3 ml soln Q4H Dose safe? Time due this shift PRN Expected effects on this patient
REACTION(S): May reuse this information for subsequent patients by copying and pasting it in.
What should you check before giving this med on this patient? Pain, type, loc, intensity What was the assessment right before and after the medication? 8/10 U.R. Leg 8/10 U.L. Chest 8/10 U.R. Leg 1/10 ½ hr Chest Major side effects (most common)
CNS: confusion, sedation GI: Constipation
Existence of gastric pain Lung sounds, pulse, BP
Dim bilat bases, rales bilat bases, before and after
CNS: Nervousness, restlessness, tremor CV: Chest pain, palpitations
Albuterol SVN 2.5 mg/3 ml soln PRN Atenolol 50 mg tab 2 tabs PO Daily (Tenormin) Bisacodyl EC 5 mg tab 1 tab PO BID Cyclobenzaprine 10 mg tab 1 tab PO BID PRN Diphenhydramine 50 mg/1 mL IV inj 25 – 50 mg / 0.5 – 1 ml IV Q$H PRN Guaifenesin ER 600 mg tab 1 tab PO BID PRN
Lung sounds, pulse, BP BP, ECG, Pulse for baseline Abd. Dist., bowel sounds Pain, muscle stiffness, ROM Itching
Manage HTN Treat Constipation Relieve cramping
BP checked q 2H No dist., hypoactive
CNS: Nervousness, restlessness, tremor CV: Chest pain, palpitations CNS: fatigue, weakness GU: erectile dysfunction Abdominal cramps, Nausea CNS: Dizziness, drowsiness EENT: dry mouth CNS: drowsiness GI: anorexia, dry mouth CNS: dizziness, headache GI: N / V, diarrhea, stomach pain
Lung sounds, freq and type of cough, type of secretions
Triamterene / HCTZ 37.5/25 mg tab 1 tab PO Daily Hydromorphone 1 mg / 1 mL IV inj 1-2 mg IV IntQ1H PRN
Prevent K+ loss / Antihyper-tensive
Hydromorphone 1 mg/1ml PCA inj 30 ml 0.2-0.3 mg IV IntQ8M
Ketorolac 30 mg / 1mL inj 15 mg, 0.5 mL IV Q6H Naloxone 0.4 mg/ml inj 0.1 mg, 0.25 mL IV PRN if RR =< 8 Nicotine 21 mg/24 hr patch 1 patch/24 hours Nitroglycerin 0.4 mg tab #25 btl 0.4 mg, 1 eA, Sublingual Daily – may repeat q5M x3 providing SBP over 90 and call physician Ondasteron 4 mg/2mL inj 4 mg/2mL IV Q8H PRN Promethazine 25 mg/1mL inj 12.5-25 mg, 0.5 – 1mL IV Q4H Famotidine (Pepcid) 20 mg / 10 mL 10 mL IV daily
BP Latest K+ levels Peripheral edema at least 1/day BP, pulse, Resps, bowel function, pain type, loc, intensity, cough, lung sounds BP, pulse, Resps, bowel function, pain type, loc, intensity, cough, lung sounds Pain type, loc, intensity Resp rate, rhythm, depth Pulse, ECG, BP, LOC HR, current patch site for reactions before replacing in new site BP, pulse, ECG
K+ levels WNL No edema
Derm: Rash, urticaria Hyperkalemia / Hypokalemia CNS: confusion, sedation CV: hypotension GI: constipation
Dim bilat bases, rales bilat bases, before and after
CNS: confusion, sedation CV: hypotension GI: constipation CNS: drowsiness Misc: anaphylaxis Hypersensitivity if opioid use > 1 week
Prevent / Manage Nicotine Withdrawal Prophylaxis for angina pectoris / Adjunct treatment of CHF Relieve N/V Relieve N/V Relieve Heartburn
HR 78 No reactions
CNS: Headache, insomnia CV: tachycardia Derm: burning at patch site, erythema, pruritis CNS: dizziness, headache CV: hypotension, tachycardia CNS: headache GI: constipation, diarrhea Confusion, disorientation, sedation
N / V, abd. Dist., bowel sounds BP, Pulse, RR
Metoclopramide 20 mg / 2 mL 2 ml IV daily Heparin 5000 U / 1 mL 1 mL q8H
Incr. gastric motility Thrombus prophylaxis
N / V, abd. Dist, bowel sounds S&S of bleeding, bruising, hematuria, BP
No N / V, bowel sounds absent BP WNL, no bruising, blood in CT drainage but not elsewhere
Drowsiness, extrapyramidal reactions, restlessness Anemia, thrombocytopenia
IV Maintenance Solution Dextrose 5% in water 500 mL IV Continuous
Medical Surgical Report (written or verbal), Nursing 212 Student: DC Collins Date: 01-27-10 Complete and communicate to the instructor before the end of shift. Patient: LS Room: 7A7 Patient Room Diagnosis/Surgery: L. Hydropneumothorax HD 6 POD 1 Diagnosis/Surgery: HD POD
Oncoming Report Summary: Age 57 male. Dr. Luber. L. CT x2 High temp evening shift. Tylenol brought it back down. 9L by mask overnight as O2 ↓ to mid 80s. Liq. diet through breakfast, adv. to normal diet as tol. No BM. Foley D/C’d. PCA 0.2 q8M Assessment Summary: Neuro: A&O x3. Drowsiness ↓ after PCA D/C’d Resp: 93% 4L mask. No dyspnea. RR 20 even Dim. Sounds / Rales bilat. bases CV: S1 S2 No extra sounds, pulses strong bilat radial / dorsalis GI: No BM since 1/24. BT hypo x4 after liq. bkfst, absent thereafter. GU: Voiding. 300 in 400 out. Skin: Clr/Tmp approp. Other: Act: up ad lib. Walks w/assist Pain: 1/10 chest, 8/10 newly rep. URLeg pain w/burning sensation & numb to touch. Medical Interventions: *Doppler ordered for leg pain. No thrombus observed *Wean off O2 *D/C Tele *D/C PCA and D5W *D/C Suction
Oncoming Report Summary:
Assessment Summary: Neuro: Resp: CV: GI: GU: Skin: Other:
MD Service, Assessment and Plan: Plan to discharge 1/29 MD Service, Assessment and Plan:
MD Service, Assessment and Plan:
MD Service, Assessment and Plan:
Interdisciplinary Team Assessment and Plan: PT: arrived when pt amb. the quad. Encouraged more of same.
Interdisciplinary Team Assessment and Plan
Interdisciplinary Team Assessment and Plan: OT assured that stay with sister after discharge arranged. OT found pt capable of self care. Nursing Team Plan: Encourage movement and ambulation 2x shift Remind to use IC and purse-lipped breathing. Observe for S&S of infection Observe O2 q2h now that he is off O2. Monitor pain, burning, sensation in URLeg End of Shift Report: *M. Age 57. *In for Hydropneumo. *Hx of ETOH. *40+ pack years *Full Code *A&O x3 *CTubes x2 left side. Slow drainage *CV: HRR, good pulses *Pulm: Dim sounds & rales bilat bases. Last O2 92% on RA *GI/Diet: Regular *GU: Voiding *Skin: Color/Temp appropriate *Meds: Percocet, Albuterol, Famotidine, Reglan, Heparin, Atenolol, Bisacodyl, Triamterene/HCTZ, Nic Patch, Reglan Mobility: Up ad lib, full ROM, rearranged his own furniture. Encourage longer amb around quad. Mood: Excellent, joking. *Pain: Controlled for chest 0-1/10. URLeg 810/10, + burning and numbness to touch, upon standing/walking for several minutes. Doppler found no thrombus. Awaiting further orders.
Interdisciplinary Team Assessment and Plan
Nursing Team Plan:
End of Shift Report:
Second and Third Patient Step 4, 5: Mini-Map, Nursing 212
Complete this form for each second and third patient during the clinical day. Indicate the problem using the priority number from the concept map. Show to instructor during the day. Use the map boxes to quickly organize data.
Student: DC Collins Patient: CF Room: ED Date: 02/03/2010 Problem General Expected Outcomes on the day of care: Priority #’s 1. The patient will report pain intensity: 0= no pain, 1-3= mild pain, 4-6= moderate pain, 7-9= severe pain, 10= worst pain imaginable, and set goal level at 3/10 or 1 better, aeb verbalization of understanding of scale and goal rating by end of first rounding after arrival. 2. The patient will report that pain management regimes relieve pain AEB report of 1 pain maintained at 3/10 or less by the end of shift. 3. The patient will exhibit reduced dizziness aeb report of reduced dizziness and 2 steadier gait on day of care 4. The patient will remain free from injury aeb no falls or other movement related 2 injury to self by end of shift 5. The patient will exhibit knowledge of symptoms of infection of which to be aware 3 aeb verbalizing those symptoms, including increase / spread of pain, fever or chills, excessive sweating, nausea. 6. The patient will remain free from additional signs and symptoms of infection 3 (other than abd. pain and dizziness) aeb core temp <99F, LOC intact, no diaphoresis, and no nausea by end of shift General Nursing Interventions: 1. Explain pain scale (as above) to patient and elicit verbal understanding of the 1 scale from the patient upon admission to ED. (E, I – No delegation) 2. Assess pain level, type, and location immediately upon arrival and q30M (A, I, EOC – No delegation) 3. Provide pain medication as ordered, prn (T, D – No delegation (narcotic)) 4. Assess level of dizziness – more or less than upon admission – more or less upon laying down / sitting upright – more or less upon movement, immediately upon admission and q30M. (A, I, EOC) – No delegation) 5. Use two side rails to prevent accidental fall from bed, escort pt to bathroom or for any necessary ambulation (possibly with wheelchair) prn throughout shift. (T, I – can be delegated 6. Provide call light and verify patient’s understanding that she should inform us if she needs anything, to ensure compliance with bed rest, upon admission and with each rounding q30M – (T, I, can be delegated) 7. Start IV NS Wide Open as per standing order 8. Assess for S&S of infection (as above #5), core temp, and LOC upon arrival and q30M (A, I, EOC – no delegation) 9. Educate patient about symptoms (as above #5) immediately upon arrival 10. Assess labs as they become available and keep physician updated ASAP EOCs not met (indicate # from above): 1: Pain was reduced shortly after each admin of 2 mg Morphine to 5/10, but quickly raised back up to 7/10 (within 30 mins of report of 5/10) 2: Pt was less dizzy when sitting upright than standing, laying down than sitting upright, and when HoB was 45 deg rather than flat. Dizziness reduced, but not eliminated 3: No additional pain or S&S of infection *except* spread of lower R. abd. pain spread to lower R. abd. 1 1 2 2 2 3 3 3
How will you modify plan? I wouldn’t. Keep pt hydrated, in bed as much as possible, assess vitals, LOC and S&S of infection often.
Priority: 1 Problem: Acute Pain r/t undiagnosed lower back pain aeb pt report and guarding -Pt reports pain 7/10 in R. lower back -Guarding of lower back and abdomen -Pain radiated to R. lower abd. during shift -Physician suspects possible appendicitis -Morphine
Priority: 2 Problem: Impaired Physical Mobility with Risk for Injury r/t dizziness aeb pt report and impaired gait -Wheelchair to bed -Pt states reduced dizziness when laying down, but still exists
Priority: 3 Problem: Risk for Infection r/t lower back pain and dizziness -Physician reports suspicion of appendicitis
Reason for Hospitalization: Dizziness – Lower Back Pain Key Assessments:
(only highest priority)
-Rocephin -NS Wide Open
-Vitals -Heart Rhythm -Orthostatic BP -Meds recently taken - Lungs / O2 Sat / Resps -Perfusion
I don’t know:
(From Schuster, P.M.: Concept Mapping: A Critical Thinking Approach to Care Planning, 2002, with permission
Name: DC Collins
ED Date: 02/03/2010
Complete this form as your clinical day proceeds. Turn into your instructor at the end of the shift. Please fill the data for your day of clinical that you did or someone else did. For IVT, complete only the information that is available to the IVT team. Most Interesting Patient Sickest Patient Another patient Rm Last name ED Rm Last name CF Rm Last name CB Reason Here: 85 y.o. F sent by Reason Here: 59 y.o. F, Dizziness, Reason Here: 27 y.o. F, Syncope nursing home for vomiting x1 R. lower back pain and SoB, 30 wks pregnant, c/o intermittent tightening stomach muscles Labs: Labs: Labs: Stool, for C-diff, results not back Awaiting labs from Allenmore UA Abnormals and reason: UA 3+ Blood 2+ Leukocytes Abnormals and reason: Abnormals and reason: UA – Urine hazy Glucose 118 H Pot 3.4 Low Total Protein 6.1 L Albumin 3.2 L RBC 3.63 L Hct 3.2 L Suspected Low Iron, inadequate nutrition, and not enough rest. Other tests today: Venous Doppler RLE LLE – no DVT seen Abd CT with contrast, awaiting results Abnormal physical assessment and times: Pain in L. lower back radiated during stay to bilat. HR: 116 initial assessment, 108 after Morphine
Other tests today: Abd. C/T – results not back
Other tests today: Abd. CT with contrast – awaiting results Abnormal physical assessment and times: IV diff. to start. Former IVDA (more than 10 years ago. BP 115/84 upon arrival. Dropped to mid 80’s/mid 50’s after 2 mg Morphine – next dose held BP 100/70 until 2 mg Morphine given, dropped to mid 80’s/mid 50’s again. Next dose held. Repeat of the above once more.
Abnormal physical assessment and times: Attempted straight cath and foley – third nurse successful on several attempts. Severe rash, bright red, both buttocks, reaching up inner thighs and to mons pubis. Severe diarrhea, very liquid, green and tarry, q5 minutes or less, and upon abd. contractions related to pain. Stool draining out of Foley
D/C’d IV in R. FA after CT – Site swollen, red, warm, painful to touch Pt less dizzy upon laying down, but still dizzy Lung sounds: Lung sounds: Lung sounds: Clear bilat Clear bilat Heart Sounds: S1, S2, no extra sounds Heart Sounds: S1, S2, no extra sounds Comfort level: Abd. and lower back Clear Bilat
Heart Sounds: S1, S2 no extra sounds Comfort level:
Comfort level: Pain 4/10,
Severe pain when rash touched, for cleaning after diarrhea or attempts to insert cath, for example. Could not state a number on a scale. time med due: Imodium ASAP, once EKG: N/A Pulse ox O2 Unable to take – hands too cold to register IV site: size solution rate R. Hand, 22Gauge, NS, Wide Open Vs: T: 97.6, P: 84, RR: 24, BP: 109/67
pain 7/10 pre-Morphine, 5/10 30 mins later. Continuous pattern across shift.
contractions pt believes are BraxtonHicks. Pain started in Lower R back, and spread to bilat lower back.
time med due: IV Morphine inj 2 mg, q30M prn Zofran - once EKG: Normal sinus rhythm pulse ox O2 95%, 94%, 96% on RA IV site: size solution rate L. Hand, 22 Gauge, NS, Wide Open R.FA, 20 Gauge, NS, Wide Open for CT, D/C’d after CT. Vs: T: 98.0, P: 55, RR: 24, BP: 96/45
time med due: IV Morphine inj 2 mg, q 30 M x3 prn IV Rocephin inj 1gm, ASAP, once IV Zofran inj 8 mg, ASAP, once EKG: Normal sinus pulse ox O2 100, 100, 100, on RA IV site: size solution rate R. hand, 20 Gauge, NS, Wide Open Vs: T: 99.2, P: 116 (before Morphine, 108 30 mins later), RR: 20 (before Morphine, 16 30 mins later), BP: 109/75, Drains: None I/O analysis: --amount
Drains: None I/O analysis:
Drains: None I/O analysis:
Too soon for analysis – IV NS wide open after scant return from Foley Physicians (service, time rounded, impressions and plan): Suspect fistula between colon/rectum and urinary tract. Other medical team members (service, time rounded, impressions and plan): N/A
Too soon for analysis, also NPO Physicians (service, time rounded, impressions and plan): Suspect appendicitis Physicians (service, time rounded, impressions and plan): Probable UTI
Other medical team members (service, time rounded, impressions and plan): N/A
Other medical team members (service, time rounded, impressions and plan): OB: FHR 135, moderate variability, 10 Accels, Zero Decels, positive fetal movement, Acc 150 bpm x30 seconds, pt. denies bleeding or rupture, no signs of B-H contractions Goals for the patient today Reduce Syncope / Improve breathing Reduce chance of PE RN activities to achieve those goals Patient laying down Reduce Anxiety Suggest OB Consult
Goals for the patient today /time needed Reduce / stop diarrhea and vomiting Improve Rash RN activities to achieve those goals IV Start IV Rocephin Collect stool sample
Goals for the patient today Reduce Pain Reduce effect of dizziness RN activities to achieve those goals Encourage slow, deep breathing Admin IV Morphine D/C infiltrated IV
Urinary Cath and collect UA sample Send for abd. CT Keep perineal area clean Provide perineal moisture barrier Expected Time to DC/Transfer: Needs before DC/Transfer: Unknown – diagnosis still to be established.
Pt. positioning Maintain NPO status until diagnosis Fall prevention Maintain hydration Hold Morphine when hypotensive Expected Time to DC/Transfer: Needs before DC/Transfer: Unknown – diagnosis still to be established.
Assess LE edema / for Homan’s Sign Maintain LE below heart level Monitor Vitals q30M
Expected Time to DC/Transfer: Needs before DC/Transfer: Unknown – no timeline established by physician
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