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

rash cart Prepare thin s! check chart "n#$rsement %ssessment &S P" #$c(mentati$n C)* m$nit$rin Prepare s(cti$n *ive es$mepra+$le ,ral care Prepare me#s -& ,ral me#s ,ral .ee#in "levate /,) Check placement /$$k -& *ive .ee#in *ive $ral me#s %.ter care T(rn patient CPPT 2i3 ban#a e! antiemb$lic st$ckin s "levate e3tremities C$m.$rt meas(res 2inish #$c(mentati$n C$py chart

6:50 ':00 ':00 ':20

':20 ':30 ':30 ':45

':45 ':50 ':50 0:00

0:00 10:10 0:10 0:20 0:20 0:25 0:30 0:45 4:00 0:25 0:30 0:45 4:00 4:30

567S-5* 8-%*5,S-S 8ecrease# car#iac $(tp(t r!t altere# hearth rhythm s! chr$nic atrial .ibrillati$n -n e..ective air9ay clearance r!t retaine# secreti$ns %n3iety r!t ac(te an# perceive# threat t$ bi$l$ ical inte rity s!t invasive pr$ce#(res Per #ia n$ses n(rse1 centere# an# patient1 centere# $b:ectives same as yester#ay P7,*7"SS 5,T"S:

':00 %; - assesse# the patient an# $t the .$ll$9in &S: -P1130!00, 771 20, /r!pr1 46, P1 36<4 =,C1"4&5;6< 6p$n assessment the patient $ne can n$te that the client is alrea#y in r$$m air an# t$lerates it 9ell< /is 02 sat(rati$n ran es .r$m 46 t$ 100> ':15 %; 1':30 %; %.ter assessment, - t$$k the patient C)* an# it real 1pare his 100m !#l< - then premial es$mepra+$le< The client then c$mplaine# $. #isc$m.$rt 9hich is 9hy elevate# the hea# $. his be#< -t is 9ell t$lerate#< The client is als$ has been -& me#icati$n $. mer$penem - h$$ke# it be.$rehan# s$ that by the time his $ral me#s are #(e, it 9ill als$ be #$ne< - als$ t$$k the time t$ prepare the clients me#s an# $ral .ee#in the client $ral care 9as als$ $r#ene#< ':45 10:00 %; - p$siti$ne# the client $n the be# beca(se he 9as $ #isplaye# $n a l$9er p$siti$n< 0:$$ 0:24 %; - s(cti$ne# his secreti$ns an# et minimal 9hitish l$$se secreti$ns alth$( h there 9as still marke# sh$nchi a.ter9ar#s< -t seeme# t$ that the secreti$ns are still n$t bein m$bili+e# by the #iet an# - p(t it in back $. my min# t$ per.$rm t(rnin !CPPT $n him later< - then pr$cee#e# t$ ive his #(e $ral me#s an# $ral .ee#in < - als$ t$$k the $pp$rt(nity t$ hy#rate him since he re.(se# t$ #rink sips $. 9ater #(e t$ #ysph ia an# ave e3tra 30cc $. 9ater in his .l(shin < 0:30 %; Client c$mplaine# $. #isc$m.$rt s$ - rep$siti$ne# him $n his be# an# elevate# the hea# $. his be#< - als$ p(t pill$9 at the base $. his hea# as re?(este#< - als$ t$$k the time t$ per.$rm CPPT an# t$ elevate the clients e3tremities< 0:45 %; - ans(ltate# cackles at the bases $. the clients l(n s s$ - enc$(ra e him t$ per.$rm #eep breathin s$ that he can e3pect$rate it later< 4:00 %; Since there 9as n$te# pittin e#ema $n b$th (pper e3tremities, - ban#a e# his 7 an# l .$rearms< This is als$ in c$n$mice 9ith #$ct$r hernan#e@+ $r#ers< )e.$re ban#a e his = .$rearm - .rist 9aite# .$r his -& me#icati$n Amecr$penB t$ be t$tally in.(se#< %s $bserve#, the clients 02 sat(rati$n is maintaine# at 401100>< it is hi hly liely that he is s$$n t$ be trans.erre# t$ a r$$m!9ar#< %88-T-,5%= =%)S:

)l$$# chemistry1 t$ assess renal an# liver .(ncti$ns as 9ell as t$ #etect electr$lye imbalance in the b$#y< T$tal pr$tein %lb(min Calci(m Ph$sph$r(s -nterpretati$n )acterial screenin : t$ #etermine the presence $. path$ ens in respirat$ry tract "T% ;5 S?(am$(s epithe#$l cells *ram AEB c$cci in pains *ramA1B bacilli 7es(lt D10 D10! =P2 315 !,-2 011! 012 5$rmal 65 1 01 35 1 40 2<15 2<5 0<01 1< 44 %ct(al res(lt 52 C 16 C 1<06 C 1<52 C

-nterpretati$n: this c(lt(re test $. the clients en#$tracheal aspirate in#icate that he has ram bacilli in his respirat$ry tract< %s 9ell as ram AEB c$cci in pairs< )ase# $n this .(t(re test may re?(ire# t$ i#enti.y kin# $. bacteria present s$ that appr$priate antibacterial treatment may be starte#< F,75%= %7T-C=" 7"%CT-,5 S$(rce : /err, k< C$yne, p< man 9$man, 71 ;cca..ery, ;< ;erket S, pel$s Gelley, F 9il# = A2006B pain assessment in the n$n verbal patient p$siti$n statement 9ith clinical practice rec$mmen#ati$n %merican s$ciety .$r pain mana ement n(rsin &,=',n$2 A :(ne B PP< 44152 The article presents p$siti$n statement an# clinical practice rec$mmen#ati$ns assessment in the n$n verbal patient< /ere are the imp$rtant p$ints iven in the article: %ll pers$n T pain #eserve# pr$mpt rec$ niti$n an# treatment Pain sh$(l# be m$tively m$nit$re# assesse#, reassesse# an# #$c(mente# clearly t$ .acilitate treatment an# c$mm(nicati$n am$n health care clinicians -n n$nverbal patients alternative meth$#s an# assesstment sh$(l# be (se# -n hist$ry $. pain assessment inv$lves: 1< Sel. rep$rt

2< P$tential c$(rses $. pain

3< P$tential behavi$rs 4< S(rr$ ate rep$rtin Asi ni.icant $thers etc<B 5< %ttempt anal esic trial This article help me in my c$re beca(se the (s(al t$$ls .$r assessment A&%S, .aces pain scaleB 9ere n$t a#e?(ate t$ assess pain 9hen the client 9as still int(bate#< This 9as especially help.(l 9hen 9hen 9e ha# a #iscrepancy in #$c(mentati$n $. anal esia sc$re< This s(pp$rts the asserti$n that the patient sel. rep$rt is still the n(mber $ne t$$l .$r pain assessment< %ll in all the :$(rnal article ma#e my assessment $. the .i.th vital si n A pain B m$re acc(rate an# realiable< /-*/=-*/TS T$#ay - $t the $pp$rt(nity t$ a ain rely $n *,8s race< 8espite the na(sea an# 9eakness that - still .eel, - 9as able t$ per.$rm my .(ncti$ns as a n(rse even th$( h - #$ n$t have a partner :(st like my $ther classmate - m very thank.(l $. it alrea#y< % ain -@ve learne# a l$t .r$m $(r master st(#ents as they s(pervise# (s in the be#si#es< The inter acti$ns 9ith them via case presentati$n als$ pr$ve# (se.(l .$r me< They $t t$ veri.y my P" .in#in s an# - am la# that these .in#in s are in c$n mence 9ith theirs< T$#ay, - have als$ learne# the val(e $. time mana ement - believe# that t$#ay< - have .inishe# earlier than (s(al beca(se by 0:30, - 9as :(st 9aitin .$r my -& me#icati$n t$ be t$tally in.(se# s$ that - can c$mplete my c$m.$rt meas(re re?(ires by p(ttin ban#a e $n my clients le.t han#< - am als$ very happy ab$(t the pr$ ress that my clients makin as he is #$in ?(ite 9ell an# is nearin trans.er t$ 9ar#< 5(rse1 centere# $b:< 5(rse 9ill: 1< -mplement plan $. $. c$me as planne# 2< ;ana e time by stickin t$ time an# activity plan as appr$priate 3< %ssess patients states th$r$( hly 4< Per.$rm CPPT s(cti$nin t(rnin an# appr$priate

Clients1 centere# $b:<

Clients 9ill: 1< 8isplay hem$#ynamic stability 2< 7ep$rt Cepis$#es $. #yspnea 3< 8em$nstrate e..ective e3pect$rati$n $. secreti$ns 4< 8em$nstrate #ecrease a itati$n! lessene# an3iety

September 23, 2011 P7,*7"SS 5,T"S 5ame $. patient: "rnest$ ;en#$+a 8ate $. a#missi$n: 4!14!2011 ;e#ical #ia n$sis: hces$pha eal mass, %72, a+$temia "n#$rsement: /epl$ck at =1 metacarpal vein elastic ban#a e1re =east 0 am 5*T p$ssible trans $(t ,ral .ee#in 222cc .$r c$n#$m catheler inserti$n .$r apply antiemb$lic st$ckin s A$n 9ashin B 6:30 %; - receive# the patient asleep s$ - #i# n$t 9ake him (p yet, instea#, :(st like yester#ay, - assesse# 9hat - c$(l# #$ at that p$int< - n$tice# that his 77 is 22 bpm, his /7 is 00 bpm< %.ter a 9hile he 9$ke (p an# his )P 9as 140! '0 mm!t < /is e4v5m6< ;y P" assessment! .in#in s are .$ll$9s: Hc$nsci$(s c$nherant, l$$ks acc$r#in t$ a e, appears cache3ic H &%S 2!10 Hpale skin, AEB milky #ischar e I=1.$rearm ive .re?(ent sips $. 9ater apply

H.air t(r $r, r$( h, #ry skin Hn$rm$cephalic hea#, .ine hair, clean scalp, A1B masses Hsymmetrical li#s, pale c$n:(nctiva Hanisteric sclera, e?(al p(pil si+e 3mm Hbrisk reacti$n t$ li ht, (ni.$rm acc$mm$#ati$n, (ni.$rm c$nver ence Hn$rm$set ears,A1B #ischar e Hpale lips, t$n (e I mi##le, c$mpletely missin teeth, pinkish (ms, pinkish m(c$sa Hsymmetrical mas$labial .$l#s H7 n$stril patent, = n$stril T 5*T Hn$n ten#er sin(ses Htrachea at mi#line Hn$n plalpable lymph, n$#es H.l$t perc$r#ical area, P;-I 5th -CS =;C=, apric$t beat I4th =CS H s - Ds2I base, s- Hs2 I ape3 H#istinct b(t irre (lar heart s$(n#s H 1:1 H1:2 -!" rati$ %P= rati$

HAEB $ccasi$nal rh$nchi I bilateral l(n .iel#s H l$b(lar ab#$men, A1B lesi$ns Hn$rm$active b$9el s$(n#s : 14!min HA1B m(scle (ar#in , A1B ten#erness Hperipheral p(lses an# assesse# #!t e#ema Hpale nailbe#s C7TJ 3 sec<

HAEB peripheral e#ema, ra#e 2, pittin

C,5T7%PT-,5S:

T hepl$ck I=1metacarpal vein, A1B entherma, A1B ten#erness,A1B 9armth ,thers: r$$m air 9ell t$lerate#, 02 sat< 461 100> "C*: a< .ibrillati$n T $ccasi$nal P&Cs

':00 %; The n(rse t$$k his C)* an# it rea# 140 m !#=< )eca(se $. this he 9as iven 4 (nits $. ins(lin AS%-B vai s(bc(ntani$(s r$(le at ab#$men 7=K A0%;B< ':05 %; - prepare# his premeal es$mepra+$le s$ that he can have it be.$re the 0 %m .ee#in < 5e3t beca(se the client has an#ible rch$nchi< - enc$(ra e him t$ e3pe#$rate by teachin him h$9 t$ per.$rm h(.. c$( h an# #eep breathin < /e e3pect$rate# m$#erate yell$91 br$9n thick sp(t(m< ':15 %; The client 9as iven his #(e es$mepra+$le via 5*T a.ter the /,) 9as elevate# an# the 5*T placement 9as checke#< -t 9as 9ell t$lerate#< ':20 %; ,ral care 9as #$ne (sin )acti#$l an# c$tt$n ple# ets ':23 %; - $..ere# the client sips $. 9ater< /e sippe# ab$(t 10 cc $. 9ater ':231':55 %; Prepare# me#s: -&1;er$penem in 10cc sterile 9ater ,ral1m$riamin .$rte 1rebepami#e 9ater, straine# 9! *%6L" 1#$lcet 1al#act$ne ':5510: 00 in 10cc #istille#

Helevate# hae# $. be# t$ 30 #e ree, 9ell t$lerate# Hchecke# 5*T placement, in place an# intact H$ral .ee#in iven 9ell t$lerate#

H$ral me#icati$ns iven 9ell t$lerate# H-& me#icati$n mer$penem@s s$l(set 9as prepare# b(t my b(##y n(rse t$l# me t$ ive the ne9ly $r#ere# #5050E/7 t$ the client .irst since the client $nly has $ne line<

0:14 %; Ha.ter c$me #$ne 0:20 %; Ht(rne# patient t$ 7 lateral si#e HCPPT #$ne Ap(lm$nary clappin B Hstill T n$n pr$#(ctive c$n hin 0:30 %; H%#ible sh$nchi, AEB n$n pr$#(ctive c$( hin H enc$(ra e client t$ per.$rm #eep breathin Hta( ht h(.. c$( hin Henc$(ra e t$ sip 9ater appr$3 30 cc v$l(me Hstill T n$npr$#(ctive c$( h 0:40 %; H)an#a e $n .$rearms in tack in place Hl$$se# ban#a e in = an# 7 .$rearm as $r#ere# H= an# 7 .$rearm AEB .$r e#ema ra#e 1, pittin 0:45 %; Helevate# e3tremities as $r#ere# H 9ell t$lerate#

0:50 %; H02 sat(rati$n m$nit$r br$ken H)P app$rks t(bin s br$ken Hattemple# t$ .i3 02sat m$nit$r an# )P apparat(s H)P apparat(s 9as .i3e# b(t 02 sat(rati$n m$nit$r remaine# br$ken 4:00 %; H%ssiste# PT ;s< 2ernan#e+ in passive an# active 7,; e3ercises H9ell t$lerate# 4:30 %; HC$n#$m catheler applie# (sin aseptic techni?(es HA1B #ischar e penis A1B in.lammati$n Hpatient T c$n#$m catheler #rainin t$ (rine ba 4:40 %; H5$te# n$ns$ake# #iaperAEB (rine, li ht yell$9ish A1B st$$l Hchan e# #iaper HT #iaper intact 9ell t$lerate# 4:50 %; H%ppeare# n$t in ne(tral p$siti$n Hrep$siti$ne# $n be# Harran e# pilli$9 t$ acc$m$#erate hea# an# sh$(l#er Helevate# hea# $. be# t$ 30 #e ree 10:00%; Hret(rne# br$ken 02 sat(rati$n m$nit$r an# )P apparat(s t$ b(##y n(rse Helevate# hea# $. be# t$ 30 #e ree

S6;;%7M ,2 C%7"! P%T-"5T 7"SP,5S"

The .irst #ay $. care .$r the patient 9as centere# $n keepin him 9ell ventilate# an# 9ell1 per.(se#< ;eas(res like #eep breathin , #rainin , mechevent settin s, m$nit$rin 77 rate an# #epth $. breathin 9as Prevalent< The clients pain 9as als$ a##resse# by the n(rse< The patients c$m.$rt sec(re#< $n the sec$n# #ay the n(rses assessment 9as brie.ly interr(pte# by 2 n$te #ecrease in breath s$(n# an# $ccati$nal s$(n# 9hich 9as attrib(te# t$ 2 m(c(s play a.ter havin .$(n# in an attempte# s(cti$n that $nly hal. $. the acti$n can be acc$mm$#ate# by the "T< Te pr$blem 9as a##resse# by neb(lli+ati$n an# instillati$n $. sterile 9ater t$ s(cti$nin < c$m.$rt meas(re can als$ per.$rme# an$ther rec(rrent pr$blem $. the client is his a itati$n< the client is c$mplainin #i..ic(lty $. breathin b(t a.ter checkin the mechevent, its t(bes< The "T .$r Asecreti$nB as 9ell as the 02 sat(rati$n, - .$(n# $(t that n$thin is 9r$n 9ith them< in .act client 5202 9as at 100><the pr$blem it seeme# 9as m$re $. an3iety $n the part $. the patient beca(se i. s$me$ne stay in his si#e, his breathin ret(rns t$ n$rmal< )eca(se $. this $ne $. the interventi$ns 9as t$ acc$mpany the client in times $. an3iety< - als$ re e3plaine#! re in.$rme# 9hat the .ell$9 $n #(ty an# n(rse $n #(ty t$l# him ab$(t mechanical ventilat$rs p(rp$se< C$m.$rt meas(res 9ere als$ #$ne< ,n the thir# #ay the n(rsin interventi$ns $. the n(rse 9ere .$c(se# $n a##ressin in e..ective air9ay clearance $. the clients by havin timely s(cti$nin CPPT t(rnin an# #eep breathin a ain his an3iety re ar#in his mechanical ventilat$r 9as re assesse# an# a##resse# (sin the same techni?(es that 9$rk previ$(sly $n him< Pain 9as als$ a##resse# by a#ministerin P75 pain me#icati$n< C$m.$rt at the patient 9as ens(re# by keepin him in ne(tral p$siti$n p(ttin $n elastic ban#a e< %ntiemb$lic st$ckin s an# elevatin e3tremities< This als$ increases per.(si$n $. peripleries an# #ecreases e#ema $. patient< Nhat is n$table .$r the client $n the 4th #ay is his bi leap .r$m mechvent t$ r$$m air< % ain the .$c(s $. my interventi$n centere# $n the clients m$bili+ati$n $. secreti$ns as he is still n$t be able t$ e3pect$rale< th$( ht him c$( hin techni?(es an# s(cti$ne# $ral secreti$ns< CPPT t(rnin an# hy#rati$n 9ere als$ per.$rme#< ,n the last #ay $. #(ty, the n(rse attempte# t$ a ain c$nvince the client t$ sip 9ater $r#ere#< -t 9as very m(ch appreciate# by the n(rse 9hen the patient a ree# t$ #$ s$, n$t $nce b(t t9ice< 5e3t the patient als$ learne# h$9 t$ c$( h e..ectively #(rin $ne $. $(r c$( h c$achin sessi$ns< /e 9as able t$ e3pect$rate yell$9 li ht br$9n sp(t(m in m$#erate am$(nt< The n(rse als$ n$tice# that the patient is m$re calm an# less a itate# t$#ay #espite the .act that his sertraline 9as #e.erre# by the #$ct$r<

"&%=6%T-,5 $. C%7" Pr$bably am$n the str$n p$ints $. my n(rsin care is that - 9as able t$ establish a $$# n(rse patient rep$rt< )y the en# $. my #(ty, - am able (n#erstan# my patient better an# $n anticipate his nee#s< - 9as able t$ impr$ve the 9ay - mana e my time an# activities in s(ch a 9ay that - can be m$re e..icient 9ith$(t c$mpr$misin ?(ality $. care< Nith re ar#s t$ interacti$n - believe that 9ith time an# the increase# .re?(ency $. havin per.$rme# a certain pr$ce#(re, - 9as able t$ ain c$n.i#ence in per.$rmin them< This is the 9$r#s 9hen - .irst e3perience# n$9 t$ in:ect ins(lin the .irst 9here - $t t$ $perate an# tr$(ble sh$$t 2 mechanical ventilat$r< / is als$ the .irst time that - have enc$(ntere# a patient 9h$ is an3i$(s an# #eman#in at the same time an# - believe 9ith time, - 9as able mana e even the patient@s behavi$r< Nith re ar#s t$ my patient, - am ?(ite happy that his 9eanin is #$in 9ell an# that he is s$$n t$ be trans.erre# t$ the 9ar# 9here he can be 9ith his .amily< -n tr(th, - believe - 9ill miss tatay "rnest$ an# $(r sessi$n@s $. #ealin 9ith his an3iety %s t$ the impr$vement $. my care, - believe that bein m$re certain $. rati$nals an# rea#in recall $. previ$(s less$ns 9$(l# still impr$ve my per.$rmance< - c$(l# als$ (se $ne $. my previ$(s as i. its n$t #$c(mente#

%88-T-,5%= "&%=6%T-,5 $. ST%22 %lth$( h - have previ$(sly eval(ate# the sta.. - 9$(l# like t$ re eval(ate a ain beca(se - n$tice# s$me chan e in them< =ast 9eek - n$tice# that n$t all $. them seem t$ tr(st (s en$( h t$ let (s per.$rm $(r n(rsin care by $(rselves b(t this 9eek - n$tice# that they 9$(l# leave me at the be# si#e an# $nly ask .$r (p ra#es $ccasi$nally< - believe# that a.ter $(r t9$ 9eek #(ty $(r relati$nship 9ith the sta.. has impr$ve#<