Student: Steven Lukac

YOUNGSTOWN STATE UNIVERSITY

Date of Care 2/28/2020
Department of Nursing
Nursing 4840L Clinical Data Base
Pt’s Initials S.R. Height 6’
Adm. Weight
Isolation type none 232 lbs 12.9oz
Allergies not on file

Diagnosis (es): trauma w/ subdural hematoma

Chronic Myelocytic Leukemia, acute cervical myofascial strain, previous acute respiratory failure

Reason for Admission/Events Leading to Current Hospitalization:

(Include reason patient is still in Unit > 2 days if appropriate)
Found unresponsive in cell from an assault, head was hit on nearby furniture causing loss of consciousness, pt. began to deteriorate. Pt.
was brought to ED and was intubated PTA with a GCS of 3. Given Keppra and maintained on propofol, later taken to OR for
emergency craniotomy
@ risk for reintubation d/t upper airway secretions, unstable for transport

Pertinent History of Illnesses/Surgery:

Subdural hematoma requiring craniotomy w/o bone flap removal to evacuate blood (2/24/2020)

Day of Care (ranges): Vent Settings:

T 101F
ETT (size/lip-line) Trach (size/type)
BP 136/54
Vent: Mode
MAP 73 Rate
HR 76 FiO2
RR 21
TV
SPO2 (range) 94%
PEEP
PSV
Oxygenation (circle):
N/C HFNC @15L
FM Venturi NRB FiO2
CPAP BiPAP FiO2
Neurological:
LOC: awakens to voice Orientation: A&O x4 (to person, place, time, and situation) Ordered Sedation: none
Opens Eyes: to speech GCS: 13 Pupils: 3mm, brisk reaction to light, accommodation bilaterally
Speech: slurred Tongue: pink, moist, and intact Face Symmetry: Symmetrical, swollen L eye

Cardiovascular:
Rhythm: NSR Pulse: Regular Cap Refill: (<3 sec) JVD: none Cyanosis Location: none
Pacemaker: none Heart Sounds: S1, S2 CVP: not taken PCWP: not taken

Peripheral Vascular:

Pulses: Palpation Radial: R 3, L 3 Pedal: R 2, L 2 Post Tibial: R 2, L 2

Edema: No Degree: -
Location: -

Respiratory:
Breath Sounds: R middle lobe and upper lobes clear, bilateral lower lobes crackles Sputum: on nasotracheal suction
Chest Tubes (Location/system/Sx setting): none Cough: nonproductive cough

GI:
Diet: NPO TPN: - TF (type/rate): standard with fiber @20mL/hr NG/OG/PEG/FT (circle)
Bowel Sounds: active in all 4 quadrants Ostomy (type): none NG Sx Drainage: none Stool: No
FMS: none Abdomen: soft, round, nondistended, no guarding Incontinent: N Color/charac: none observed on shift

GU:
Urine: Color yellow clarity clear amount 445 on shift catheter type/size Foley catheter, 16 French
Genital Irritation: No dialysis no dialysis

Skin:
Temp: entire body is warm color: appropriate for ethnicity turgor: no tenting
mucous membranes: moist, pink, and intact incisions: top of head, L side (craniotomy)
Wounds: anterior L proximal hip; L upper lateral arm

Musculoskeletal:

Upper Extremities:
Movement R full movement, L limited movement strength R moderate, L weak sensation R full, L decreased/numb
Lower Extremities:
Movement R full movement, L limited movement strength R moderate, L weak sensation R full, L decreased/numb
Continuous IV Drips: IV Drips must also be looked up & included on Med Sheet
Medication Concentration Rate Site Line
0.9% Sodium Chloride 0.9% 100mL/hr L subclavian TLC

nicardipine 50mg in 0.9% NaCl 100mL 10mL/hr L subclavian TLC

Intake/Output/Weight:
24 hr. Intake: 2758 24 hr Output: 1655 Cumulative Fluid Balance (prior day): +1103
6 hr. Intake: 760 6 hr Output: 445 Daily Wt (today): 233lbs 11oz (prior day): 232lbs 12.9oz

Pain/Pain Management:
Location: head, incisional Duration: on movement Scale 1-10: 5
Intervention: tylonol given Evaluation (w/in 30 min): reported pain of 3

ABG Analysis:

ABG’s: pH PCO2 PO2 HCO3 Interpretation

Admission 7.39 41.4 147.8 24.5 Normal

Date:
Day prior None ordered
Date:
Day of care None ordered
Date:

Diagnostic Test: Results:

Chest X-Ray 2/24: suspected L sided rib fx

(include date) 2/27: tube positions as noted, new areas of opacification R basilar
Other pertinent 2/25: CT head w/o contrast – improvement of L to R shift post craniotomy. Possible findings of
diagnostic tests
transependymal spread of CSF adjacent to R occipital horn
(include date)
 Normal Admission Day prior
Day of care
Lab Test Values Reason for Abnormal Value
2/24 2/27 2/28
Date
+
Na 132 – 146 138 145 145
K+ 3.5 – 5.0 4.5 3.7 3.7
Cl- 98 – 107 103 110 109 Rising in relationship with sodium level
CO2 22 – 29 25 25 26
BMP

Glucose 74 – 99 153 193 232 Stress of situation and possible infection

BUN 6 – 20 14 17 18
Creatinine 0.7 – 1.2 0.9 0.7 0.8
Calcium * 8.6 – 10.2 8.5 8.5 8.2 Low d/t low albumin value
Albumin 3.5 – 5.2 3.4 2.9 2.6 Malnutrition
CMP (+ BMP)

Total protein 6.4 – 8.3 5.9 5.5 5.2 Malnutrition

ALP (Alk Phos) 40 – 129 113 83 104
ALT/SGPT 0 – 40 42 21 18
AST/SGOT 0 – 39 46 24 26
Total Bilirubin 0.0 – 1.2 0.5 0.5 0.5
Magnesium 1.6 – 2.6 2.1 2.2 2.0
El

Phosphate 2.5 – 4.5 3.4 3.4 3.0

Cholesterol 0-199 - - -
Lipid

Triglycerides 0 – 149 - - -
Chronic Myelocytic Leukemia causing bone
RBC 3.8 – 5.8 3.6 2.99 2.88
marrow dysfunction; subdural hematoma
CML causing bone marrow dysfunction;
Hgb 12.5 – 16.5 10.9 9.0 8.7
subdural hematoma
CML causing bone marrow dysfunction;
Hct 37 – 54 32.9 27.7 26.5
subdural hematoma
Platelets 130 – 450 835 832 766 CML causing bone marrow dysfunction
CBC

CML causing bone marrow dysfunction;

WBC 4.5 – 11.5 206.2 258.2 237.7
possible infection AEB inc. temperature
neutrophils 43 – 80 56 47.7 69
lymphocytes 20 – 42 10 3.1 1 CML causing bone marrow dysfunction
monocytes 2 – 12 2 5 4
eosinophils 0–6 2 0.3 2
basophils 0–2 1 3.5 1
PT 9.3 – 12.4 14.4 - -
Coag

INR 1.0 1.3 - -

HPTT/PTT 24.5 – 35.1 33 - -
CK - - -
Cardiac

CK MB - - -
Troponin 0.00 – 0.03 - - -
B-type natriuretic peptide (BNP) - - -
Lactate 0.5 – 2.2 1.1 - -
Other

Ammonia - - -
GFR >60 >60 >60
ECG Interpretation:
Post 6 second ECG strip here or on back (no identifiers). Interpret using 8 step method.

ECG Analysis:

1. Rate: 90 2. R-R Interval Regular: yes

3. P wave present: yes 4. PR Interval: 0.16 Constant: yes
5. P precedes each QRS: yes 6. QRS Interval: 0.08
7. QT Interval: 0.36 8. ECG Interpretation: NSR

__________________________________________________________________________

Pathophysiology of primary diagnosis &/or surgery:

Subdural hematoma – collection of blood between the dura and the brain, often the result of a head trauma. Deadliest of all head injuries

due to direct compression on brain tissue

Craniotomy – removal of part of the skull to relieve pressure off of the brain. Skull can be replaced during procedure or at a later date

Book used & page no.: B&S med-surg p. 1972-1972, 2027

Psychosocial Considerations:

Traumatic stress from assault, surgery, and temporary intubation

Loneliness from lack of visitors
Allergies: ____none on record____________________________________________________________________

Times Due Cont. Cont. 0900 0815, 1615, 0015

Brand Name - Cardene Norvasc Maxipime

Generic 0.9% NaCl Nicardipine amlodipine cefepime

Name

Dose 100mL/hr 50mg in 100mL 0.9% 10mg 2g IVPB in 100mL 0.9%

NaCl @10mL/hr NaCl @12.5mL/hr
Route/How IV IV PO IV
to Administer

Classifica- IV fluids Calcium Channel Calcium Channel 4th generation

tion Blocker Blocker cephalosporin

Action Replenish fluid in the Inhibits Calcium Inhibits Calcium Binds to bacterial cell
blood transport into transport into wall leading to cell
myocardial and myocardial and death
vascular smooth muscle vascular smooth muscle
cells cells
Reason Pt Fluid maintenance Elevated blood pressure Elevated blood pressure Empiric coverage of
Receiving while NPO infection

Contra Fluid overload, Heart Sinus sick syndrome, Severe hepatic Renal impairment,
Failure 2nd or 3rd degree heart impairment, aortic history of GI disease,
block, advanced aortic stenosis, history of poor nutrition,
stenosis, hypotension heart failure, sensitivity to
hypotension cephalosporins and
penicillin’s
MAJOR Phlebitis, pulmonary Hypotension, peripheral Hypotension, Phlebitis, pain at IV site,
Adverse/ edema, heart failure, edema, arrythmias, peripheral edema, rash,
Side Effects hypervolemia tinnitus, bradycardia, angina, bradycardia, pseudomembranous
nausea/vomiting palpitations, fatigue colitis, superinfection

Nursing Assess insertion site Monitor blood pressure Monitor blood pressure May cause leukopenia,
Implications Auscultate lungs and heart rate and heart rate neutropenia,
periodically Monitor intake and Monitor intake and thrombocytopenia, and
output output eosinophilia
Assess for rash Assess for rash Observe for anaphylaxis
Pt/Family Report burning or Titrate to systolic bloop Take same time every Report signs and
Teaching swelling at the IV site pressure of <140 day symptoms of
Report difficulty Dose range: 5-15mg/hr Change position slowly superinfection
breathing Titrate no faster than Avoid copious amounts
2.5mg/hr every 15 of grapefruit
minutes

Allergies: ____none on record____________________________________________________________________

Times Due 0900, 2100 Every hour PRN Every 4 hours PRN
Brand Name Keppra Sublimaze Tylenol

Generic levetiracetam fentanyl Acetaminophen

Name

Dose 500 mg 25mcg for pain 4-6, For pain 1-3

50mcg for pain 7-10
Route/How PO IV push PO
to Administer

Classifica- Pyrrolidines Opioid analgesic Non-opioid analgesic

tion

Action Inhibit burst firing of Binds to opiate Inhibit synthesis of

the neurons without receptors in the CNS prostaglandins
affecting neuronal
excitability

Reason Pt Prevention of seizure Pain control Pain control

Receiving related to subdural
hematoma

Contra Cautious in all Cautious in head Severe hepatic and renal

patients due to injuries, increased disease
suicidal ideation ICP, COPD, other
respiratory problems,
prior addictions
MAJOR SI, aggression, Sedation, respiratory Hepatotoxicity,
Adverse/ agitation, anxiety, depression, circulatory atelectasis,
Side Effects depression, depression, nausea/vomiting
depersonalization, nausea/vomiting,
SJS hypotension
Nursing Monitor for mood Monitor vital signs Monitor AST and ALT
Implications changes and rashes Watch for respiratory levels
May dec. RBCs and depression Monitor malnourished
WBCs and cause Naloxone is antidote patients for increased
Abnormal liver effects
function tests
Pt/Family Notify if change in Report if patient stops Avoid concurrent
Teaching personality breathing or alcohol use
Change positions responding Stop taking if rash
slowly occurs
 Key Problem/ND 8
2. Impaired gas exchange

Supporting data:
Key Problem/ND: Previous ETT use d/t respiratory
1. Ineffective cerebral tissue failure this visit
perfusion On 15L high flow nasal canula
SpO2 94%
Supporting data: Respiratory rate 21 BPM Key Problems/ND
Craniotomy done to reduce ICP Upper airway congestion 3. Impaired tissue integrity
Subdural hematoma Sputum on nasotracheal suction
Slurred speech Low hemoglobin (8.7) Supporting data:
Weakness and limited movement Crackles in Lower lobes of lungs Open surgical site wound
on the L side Nonproductive cough Multiple wound sites on hip and
Wide pulse pressure (136/54) arm
Numbness to left side Low total protein level (5.2)
HR 76 Turn every two hours
MAP 73 (as stated by ART line)

Reason For Needing Health Care

(Medical Dx/ Surgery)
Subdural hematoma r/t a fall
Craniotomy to relieve ICP
56 yo male, Full code

Key assessments:
Neurologic, musculoskeletal,

Allergies:
None listed on file

4. Unilateral neglect Key Problem/ND

6. Powerlessness
Supporting data:
States dec. sensation on L side Supporting data:
Weakness on L side States lack of control and
Limited mobility on L side frustration
States cannot do anything with Attempts to take control by
this side anymore pressing call light with no
Key Problem/ND
reason as to why
5. At risk for infection
Lack of involvement in nursing
care
Supporting data:
Inability to perform ADLs
Open surgical site wound
On cefepime for empiric
prevention of infection
Central venous catheter
Arterial line
Foley catheter

Problem # 1: Ineffective cerebral tissue prefusion r/t subdural hematoma AEB need for craniotomy, slurred
speech, weak and limited movement on the L side, wide pulse pressure
General Goal: Improved cerebral tissue perfusion
 9

Predicted Behavioral Outcome Objective (s): The patient will demonstrate orientation to person, place, time,
and situation and have a normal level of consciousness (awakens to voice) during each assessment

Nursing Interventions Patient Responses

1. Monitor blood pressure, pulse, level of 1. BP- 136/54, P-76, patient awake and responds to
consciousness, pupillary reflex voice, pupillary reflex present
2. Avoid activity that raises blood pressure or 2. Minimalized activity to passive ROM, patient
obstructs venous return on bedrest
3. Semi fowlers to high fowlers positioning 3. Semifowlers positioning maintained through
4. Asses orientation level shift
5. Reorient patient as needed 4. Alert and oriented x4
5. Reorientation not needed

Evaluation of outcome objectives: Objective met. The patient maintained orientation x4 and desired level of
consciousness during each assessment.

Problem # 2: Impaired gas exchange r/t decreased respiratory tract functioning AEB previous intubation this
visit, 15L HFNC, nonproductive cough with upper airway congestion
General Goal: Resume normal functioning of the lungs

Predicted Behavioral Outcome Objective (s): The patient will have proper oxygenation with SpO2 above 95%

Nursing Interventions Patient Responses

1. Assess lung sounds 1. Lower lobes with crackles, congestion in

2. Assess SpO2 tracheal region
3. Assess rate and quality of breathing 2. SpO2 slightly below normal at 94%
4. Observe for cyanosis of the skin 3. Rate is 21, no use of accessory muscles
5. Suction as needed 4. No cyanosis noted
6. Position HOB at least 30 degrees 5. Nasotracheal suctioning performed with large
amounts of sputum
6. HOB maintained at 30-45 degrees through shift

Evaluation of outcome objectives: Objective not met. Patients SpO2 stayed between 93% and 94% during
shift.
 10

Problem # 3: Impaired tissue integrity r/t surgery and fall AEB surgical wound, wounds of L hip and arm
General Goal: Skin will heal from previous injuries

Predicted Behavioral Outcome Objective (s): The patient will have no further breakdown of skin and
continued healing of surgical site during this shift

Nursing Interventions Patient Responses

1. Assess nutritional status 1. Low hemoglobin (8.7), hematocrit (26.5), RBC

2. Monitor surgical site and injuries for change in (2.88), albumin (2.6), and total protein (5.2)
color, redness, warmth, or swelling 2. No redness or warmth, surrounding skin
3. Teach patient to not scratch at wound sites appropriate for ethnicity, swelling at surgical
4. Turn Q2 hours to prevent further tissue breakdown site. No change in injuries in relation to color,
5. Assess for new areas of skin breakdown at redness, warmth, swelling,
restraint sites 3. Patient verbalizes understanding of not itching
4. Patient turned Q2 hours
5. No new areas of skin breakdown noted

Evaluation of outcome objectives: Objective met. The patient had no new breakdown of skin and skin
integrity was maintained. Surgical site and injuries continue to heal.

Problem # 4: Unilateral neglect r/t brain tissue damage AEB dec. sensation, weakness, and limited mobility on
L side
General Goal: Learn to take care of affected side in a safe and effective manor

Predicted Behavioral Outcome Objective (s): The patient will remain free of injury on my shift

Nursing Interventions Patient Responses

1. Assess for improvement in sensory, movement and 1. No change, L side has dec. sensory w/
strength on affected side numbness, weakness, and limited mobility
2. Implement fall prevention 2. Fall band on patient, yellow fall risk socks on,
3. Position affected extremity in a safe and functional 4/4 side rails up
manner 3. Affected side positioned safely and in view
4. Set up the environment so that items are near the 4. Supplies set up for patient on unaffected side
unaffected side 5. Patient states understanding of teaching
5. Teach client to scan affected side to ensure safety

Evaluation of outcome objectives: Objective met. Patient remained free of injury during this shift.
 11

Problem # 5: At risk for infection r/t surgical wound AEB open wound, central venous catheter, Foley
Catheter
General Goal: No infection during hospitalization
Predicted Behavioral Outcome Objective (s): The patient will show no signs of infection on this shift

Nursing Interventions Patient Responses

1. Use standard precautions effectively to prevent 1. Washed hands upon entering and exiting room,
contamination used clean gloves during assessments
2. Monitor laboratory values 2. WBCs elevated (237.7)
3. Monitor temperature 3. Elevated temperature (101 F)
4. Assess urine for cloudiness 4. Urine not cloudy
5. Assess sputum for yellow/green color 5. Sputum on suction was clear
6. Assess surgical site 6. Surgical site without inflammation or redness
7. Evaluate using SIRS criteria 7. Pt. meets SIRS criteria: temperature over 100.4,
respiratory rate above 20, and WBCs above
12000

Evaluation of outcome objectives: Objective not met. Patient showing multiple signs of infection including
elevated temperature, elevated WBCs, meeting SIRS criteria

Problem # 6: Powerlessness r/t lack of control over situation AEB stating frustration, inability to perform
ADLs, inappropriate call light use
General Goal: Express personal control of situation
Predicted Behavioral Outcome Objective (s): The patient will state knowledge of care plan for the day on my
shift

Nursing Interventions Patient Responses

1. Observe factors related to powerlessness 1. Patient has NG tube, is NPO, in restraints,

2. Encourage verbalization of feelings weakness in L side
3. Teach stress reduction, relaxation, and imagery 2. Client states frustration towards situation from
4. Discuss plans for the day lack of control
5. Give reinforcement and praise for following 3. Patient uses TV, music, mindful breathing;
commands and participating in care denies using imagery
4. Patient understood plans: continued recovery
from surgery, respiratory therapy treatments,
possible suctioning to clear secretions.
5. Patient is now more talkative and appreciative to
staff

Evaluation of outcome objectives: Objective met. Patient stated understanding of the days activities,