Clinical Assessment Form N414

Student Name: Tiffanie Nguyen Tran Clinical Date: 03/06/2020 Assigned Unit: RICU

Age: 79 y/o Gender: Admission date: Resuscitation Status: Full

Female 03/05/2020
Admit weight: 87.9 kg Height: 5 feet 4
inches
Reason for Hospitalization:
Septic shock – UTI
Acute hypoxic respiratory failure requiring BiPAP
Flu A and H1N1
Past medical history:
Left big toe MRSA – active and healing
Cellulitis – Right leg calf
Afib
Pulmonary HTN
PVD
Diastolic CHF
Diabetes mellitus
CKD stage III
Past surgical history:
Hysterectomy
Tonsillectomy

History of present illness: Patient was being cared for at a nursing facility for MRSA on the Left big toe and
cellulitis on her right leg. Pt was taken to Altaview ED for respiratory distress, hypoxia, and decrease LOC.
Pt tested positive for UTI, Flu A, H1N1 and blood gas indicating acute hypoxic respiratory failure. Pt was
transferred to IMC RICU for farther treatment of ARF and septic shock.

Laboratory Values: Complete the table with applicable lab values, for the results/trend indicate
if value is increased or decreased from previous result
NORMAL DATE/TIME RECENT RESULT REASON FOR ABNORMAL VALUE
AND POTENTIAL SYMPTOMS
COMPLETE BLOOD COUNT
(CBC)

White blood cells (WBC) 5.0 – 145 03/06/2020 8.5

0022
Red blood cells (RBC) 4.2 – 5.4 03/06/2020 2.61 x 10^6 Low due erythropoietin deficiency
x10^6 0022 anemia due to CKD stage III
S/S of anemia: Fatigue, SOB,
orthostatic dizziness, decrease HR,
HA, pale skin
Hemoglobin (Hgb) 12 – 16 03/06/2020 8.8 Low anemia caused by chronic
1227 kidney disease - CKD stage III
S/S of anemia: Fatigue, SOB,
orthostatic dizziness, decrease HR,
 HA, pale skin
Hematocrit (Hct) 36 – 49 03/06/2020 23.8 Low anemia caused by chronic
0022 kidney disease - CKD stage III
S/S of anemia: Fatigue, SOB,
orthostatic dizziness, decrease HR,
HA, pale skin
Platelets 150 – 400 03/06/2020 284
0022
CHEMISTRY STUDIES NORMAL DATE/TIME RECENT REASON FOR ABNORMAL VALUE AND
RESULT POTENTIAL SYMPTOMS
Sodium (Na) 137 – 146 03/06/2020 140
0022
Potassium (K) 3.4 – 4.7 03/06/2020 4.5
0022
Chloride (Cl) 102 – 111 03/06/2020 102
0022
Glucose 60 – 120 03/06/2020 74
1200
Hemoglobin A1C N/A N/A N/A N/A

Cholesterol N/A N/A N/A N/A

Blood Urea Nitrogen (BUN) 8 – 21 03/06/2020 25 High due to CKD stage III
0022 High BUN in the body results from decrease
kidney filtration ability, indicating decrease
kidney function
S/S: recurring fatigue, edema in arms, legs,
or feet, trouble sleeping, muscle cramps,
urinary changes
Creatinine 0.6 – 1.1 03/06/2020 1.28 High due to CKD stage III
0022 High Creatinine in the body results from
decrease kidney filtration ability, indicating
decrease kidney function.
S/S: dehydration, fatigue, edema, SOB,
confusion
Albumin 3.5 – 5.2 03/06/2020 3.1 Low due to CKD stage III
0022 Increase vascular permeability in the kidneys
allow for more albumin to be excreted in the
kidneys.
S/S: fatigue, proteinuria, jaundice, edema in
hands and feet
Calcium (Ca) 8.4 – 10.4 03/06/2020 7.9 Low due to CKD stage III
0022 Increase excretion of Calcium due to
increase vascular permeability.
S/S: dysrhythmias, muscle spasms, seizures,
tingling in hands and feet
Phosphorus N/A N/A N/A N/A

COAGULATION

Prothrombin time (PT) N/A N/A N/A N/A

International normalized ratio N/A N/A N/A N/A

(INR)

Partial thromboplastin time (PTT) N/A N/A N/A N/A

LIVER FUNCTION

Bilirubin 0.1 – 1.2 03/06/2020 0.7

0022
Alkaline phosphatase 40 – 120 03/06/2020 358 High due to CHF leading to liver damage
0022 S/S hepatic dysfunctions, weakness, weight
loss, N/V, jaundice
ALT (alanine aminotransferase) 0 – 40 03/06/2020 184 High due to CHF leading to liver damage
0022 S/S malaise, fatigue, poor appetite, abdomen
pain, N/V, jaundice
AST (aspartate aminotransferase) 9 – 40 03/06/2020 788 High due to CHF leading to liver damage
0022 S/S malaise, fatigue, poor appetite, abdomen
pain, N/V, jaundice
ADDITIONAL LABS

CK N/A N/A N/A N/A

Troponin 0 03/05/2020 0.81 May be elevated due to sepsis, CKD

0746 stage III, or CHF

03/06/2020 0.60 Leveling off, peak of cardiac damage

1156 has subside

S/S: CP, tachycardia, SOB, N/V, cold

sweat, fatigue.
B-natriuretic peptide (BNP) 0 – 100 03/06/2020 2396 Very high due to Diastolic CHF
0022 S/S: Dyspnea, fatigue with unknow
cause, rapid weight gain, tachycardia,
inability to concentrate
Ammonia

Arterial Blood Gas (ABG) NORMAL DATE/TIME RECENT REASON FOR ABNORMAL VALUE AND
RESULT POTENTIAL SYMPTOMS
pH 7.35 – 7.45 03/06/2020 7.399
1227
pC02 35 – 45 03/06/2020 39.6
1227
PaO2 60-80 03/06/2020 267 High O2 dude to increase oxygen
1227 therapy delivered. Pt was complaining
of difficulty breathing and shows signs
of respiratory distress. Team placed her
first on 15L/min Non-rebreather mask
and then placed her on BiPAP.

HCO3 22 – 26 03/06/2020 24
1227
Oxygen saturation (SaO2) 90-100 03/06/2020 97%
1227
Lactic Acid 0.5 – 2 03/05/2020 7.4 High due to areas of hypoxia. Decrease
1938 amount of oxygen results in Aerobic
metabolism. Aerobic metabolism results
03/06/2020 1.1 in byproduct of lactic acid
0746
S/S: extreme fatigue, muscle pain, body
weakness

Allergies: NKDA Type of Reaction: N/A

Invasive Lines

Peripheral IV Access Site Assessment YES NO

IV site and catheter gauge: IV dressing dry, no edema, redness of site X

Left AC 20G

Central Access (CVC) Site Assessment YES NO

Central line site: # of lumen: Alcohol caps present (if used) X

Right Basilic vein Double Alcohol present on both lumen

Indication for line: Dressing dry and intact X

IV antibiotics for MRSA
Arterial Access Insertion Site/Pressure Bag Assessment YES NO

Access site: Dressing dry, no edema, redness of site X

Right Radial Artery Site was swollen with signs of ecchymosis

Pressure bag fully inflated, Bag fluid (NS), assessment

of volume remaining, and zeroing of transducer

Line was DC 03/06/2020 at 1310

Physical Assessment
Glasgow Coma Assessment
Eye opening response Score 4

Verbal response Score 5

Motor response Score 6

Additional comments for any abnormalities:

 For any GCS <15, please note specific criteria that was abnormal.
GCS of 15 No abnormalities
Pupil Assessment
Right pupil size Size: 3 mm

Left pupil size Size: 3 mm

PERRLA YES: X NO:

Neurological
LOC: Describe orientation
A&O x 4 to person, place, situation, and
displays ability to critical think.
Able to follow commands YES NO

Grip equal, bilateral YES NO

Sensation intact to all extremities YES NO

Speech clear YES NO

Sensory deficit (hearing, vision, taste, smell) YES NO

Dizziness, vertigo YES NO

Use of assistive device (glasses, hearing aids) YES NO

Gag reflex intact YES NO

Additional comments for abnormal assessment findings:

Pt displays increase pain sensitivity to touch in all extremities.

Cardiovascular Additional Detail

Cardiac monitor YES NO Rhythm Interpretation: NSR with occasional
PVC

Pulses (radial, pedal) palpable, equal, strong YES NO

Normal heart tone (S1, S2), regular YES NO

Capillary refill (<3 seconds all extremities) YES NO

 Extremity temperature warm to touch, YES NO
bilateral upper and lower extremities

Edema presence YES NO Specify location and degree 0-4 scale

Bilateral lower leg edema, +2 pitting
Pacemaker YES NO Specify type (temporary, permanent)

CVP monitoring YES NO Transducer zeroed, pressure bag checked for

fluid/pressure level, no air present

Pulmonary Artery catheter (Swan) YES NO Transducer zeroed, pressure bag checked for
fluid/pressure level, no air present

Respiratory Additional Detail

Respiration pattern regular without effort
Use of accessory muscles
Productive cough
YES NO Increase respiratory effort.
At the beginning of shift patient was able to
tolerate 2L/min NC.
1150 after transferring patient from bed to chair
with physical therapy patient display signs of
anxiety and increase respiratory rate. Pt reported
of not being able to catch a breath and “help, I
need more oxygen”, “I cant breath”. After
consulting with nurse practioner on call we
placed her on BiPAP, which helped her
symptoms.
YES NO 1150 neck muscle use to breath. After BiPAP
patient no longer displayed accessory muscles
when breathing
YES NO

Sputum production YES NO Description of sputum:

Nonproductive cough YES NO

Lungs clear to auscultation, all fields YES NO Expiratory wheezing bilaterally upper quadrants.
More audible on the left side than the right side
Use of oxygen YES NO Specify mode and flow rate of oxygen:
Beginning of shift pt was on 2 L/min NC. End of
shift pt needed to be on BiPAP, FiO2: 50%,
IPAP: 12, EPAP: 7, rate: 12
Oxygen humidification YES NO
Chest tube YES NO Location:

Indication:

Drainage type:

Is there an air leak?

If YES, intermittent or continuous?

Water seal:

Suction: Ordered sxn level:

 Smoker YES NO Specify current or past hx:

Additional comments for abnormal assessment findings:

At the beginning of the shift patient was improving and on 2L/min NC. Pt condition was
exacerbated due to anxiety after physical therapy and moving her from her bed to the chair. After
transfer pt display signs of hyperventilation and neck muscle assistance to breath. Pt states “Help, I
need more oxygen” and “I cant breath”. Pt’s SpO2 ranged from 85-92%, we increase her oxygen to
6L/min. Pt’s SpO2 was about to remain in low 90% but patient continue stating that she was in
respiratory distress and continue with excessive muscle support help breath. Nurses placed her on
15L/min nonrebreather and coached her to take deep breaths. Pt continue to display signs of
respiratory distress despite SpO2 remaining in high 90%. NP was called in to evaluate patient, NP
ordered her to be placed on BiPAP with stat EKG and blood gas. After being on blood gas patient
stated she was feeling better, respiratory rate return to baseline, and no longer used extra muscles
support to breath.

Mechanical Ventilation
Is patient on ventilator? YES NO

Ventilator mode N/A

FiO2 N/A

PEEP N/A

Rate N/A

Tidal volume N/A

Type of airway tube N/A

Indication N/A

Noninvasive Ventilation
Is patient requiring non-invasive YES NO Specify type: BiPAP
ventilation (Bipap or CPAP)?

FiO2 50%

IPAP* 12 mmH20

EPAP* 7 mmH20

Rate (For Bipap ONLY) 12

IPAP-Inspiratory positive airway pressure; EPAP-Expiratory Positive Airway Pressure
 For mechanical ventilation:
o Was the patient sedated on a continuous IV infusion (s)? List ALL infusions ordered
for sedation.

o Was the patient restrained either with physical restraints or chemically with
paralyzing medications?

o If the patient was physically restrained, what additional assessments were completed
(including frequency) to ensure that the patient was safe?

o What additional interventions were taken to help prevent the development of VAP
(ventilator-associated pneumonia)?

 For ALL patients:

o Was a bag-valve mask (Ambu-bag) present in the room and easily accessible? YES

Gastrointestinal
Abdomen soft, nontender, all quadrants YES NO

Bowel sounds present x4 quadrants YES NO Specify: active, hypoactive, absent

Nausea YES NO

Vomiting YES NO Description:

NG tube YES NO Describe drainage color, amount,

consistency, location of tube:

Problems swallowing YES NO

Problems chewing YES NO

Dentures YES NO

Needs assistance with feeding YES NO

Enteral feeding YES NO Type of feeding tube:

Rate:
 Stool YES NO Describe amount, color, consistency:
Minimal brown and formed stool

Ostomy YES NO Describe type of ostomy, stoma site and

output:

Additional GI tubes YES NO Specify:

Additional comments for abnormal assessment findings:

Urinary
Continent, voiding without difficulty YES NO Unable to assess patient had a Foley placed

Incontinent YES NO Interventions:

Foley catheter, patent, down drain, secured to leg YES NO

Urine clear, light yellow to amber, no odor YES NO Foley drain pink-light red cloudy urine. No
foul smell noted.
Additional GU tubes YES NO Specify

Additional comments for abnormal assessment findings:

Pt had septic shock due to UTI – one of the reasons she was admitted

For ALL patients with indwelling Foley catheters:

 What additional assessments and/or interventions were completed to help in the

prevention of the development of a CAUTI (Catheter associated urinary tract infection)?

Nurse cleaned the Foley line during bed bath and took extra time to do perigenital care.

Musculoskeletal
Normal muscle tone without weakness YES NO Pt was weak and needed one person assist to
stand and transfer
Able to transfer independently YES NO One person assist to stand and transfer
 Purposeful movement, all extremities YES NO

Normal skeletal alignment/structure YES NO

Altered gait YES NO Specify unable to assess pt was not able to

stand up and walk for assessment
Orthopedic device (cast, splint, brace) YES NO Specify

Fall risk YES NO Specify rationale Pt has muscle weakness and

needed on person assist to able to able to stand
and transfer. Pt was also anxious and had
anxiety attacks when she tries to transfer
leading to hyperventilation.

Skin
Skin dry, intact, color within patient norm YES NO Right wrist around site of Art line was swollen
and ecchymosis.
Right calf and heel redness r/t cellulitis.
Mucous membranes moist YES NO

Evidence of skin breakdown YES NO Specify location:

Rashes or bruising YES NO Specify location:

Right wrist around site of Art line was swollen
and ecchymosis.

Sutures, staples, steri-strips YES NO Specify:

Wound drainage YES NO Describe drainage:

Wound drain YES NO Specify:

Braden Score 15
For ALL patients with impaired mobility:

 Was physical therapy/occupational therapy ordered on the patient? Yes

 If present, describe the exercises/activity performed? Sitting in bed, standing up, and
transferring to the chair
 Did the patient tolerate the activity? Yes, pt was able to perform all activities but had
difficulties controlling her anxiety after the transfer.
 Is there a decline or improvement in the patient’s ability since beginning therapy? Decline due
to patients anxiety
FOR ALL patients:

 Based upon your assessment findings, is your patient at risk for developing skin breakdown?
Yes, pt does not want to move and transfer due to her anxiety of being SOB. Pt also has
weakness and needs one person assist in order to move and transfer.

 What additional preventative measures have been implemented or would you anticipate
using to preserve the patient’s skin integrity?
Reposition patient q2h. Encourage patient to sit up and stand up frequently to increase
muscles strength and reduce anxiety of moving and transferring.

Pain
Pain Score 4 out of 10 (10 being severe pain, 1 minimal pain)

Characteristics Difficulty breathing in chest and feeling like she doesn’t have enough oxygen

Onset After moving and transferring.

Location Around chest and neck area

Duration Been going on and off for 2 weeks.

Exacerbation Standing up and transferring from bed to chair or to use the bathroom

Radiation Pt denies

Relief Resting and increasing oxygen support therapy

Associated Pt is unable to move and do ADL’s without anxiety that she will run out of breath
symptoms and not be able to breath

Standards of Care NO YES INTERVENTIONS ORDERED

DVT prophylaxis X SCD.

Reposition pt q2h
GI Stress ulcer prevention X
Ventilator-associated pneumonia X
(VAP)
Pathophysiology:
Provide a detailed description of the patient’s disease process. In addition to the disease
process, discuss the following items:
Risk factors (if indicated)
Contributing factors (if indicated)
Clinical signs/symptoms
Complications (possible or actual)
Treatment regimen
Acute hypoxic respiratory failure
Acute hypoxic respiratory failure develops as a result of inadequate oxygen exchange between
the alveoli and capillaries. Patient has pre-existing diastolic heart failure; this results in the left
ventricles not relaxing and filling properly during diastoles. Problems with the left side of the
heart eventually leads to back flow into the lungs. The pressure builds up in the pulmonary
vessels and this results in pulmonary hypertension. The pressure and volume build up in the
pulmonary vessels will result in increase vascular permeability, leading to more contents from
the vessels going into the interstitial space and the alveoli space, this results in pulmonary
edema. The pulmonary edema makes it more difficult to exchange gases at the alveoli and
capillaries. In additional this condition patient contracted flu A and H1N1, both respiratory
diseases. These two diseases add more inflammation to the pre-existing problem which
increases the edema in the alveoli. They also cause bronchitis which is inflammation of the
bronchioles, increase pressure or workload is then needed to get air to flow adequately to the
lungs. The patient will displays signs of upper respiratory wheezing an increase effort to breath
such as: tripod position, increase use of excessive muscles to support breathing, inability to lay
supine, complains of not getting enough oxygen. The final factor that exacerbates the patient’s
condition is her anxiety. The patient is anxious that when she moves or transfers she will not
able to adequately breath and this results in her hyperventilating. Hyperventilating and
tachypnea decreases the amount of time and area for O2 to be exchanged in the alveoli,
ultimately leading to hypoxia if not treated.

Risk Factors (if indicated)

- History of heart disease
- Obesity-hypoventilation syndrome
Contributing Factors (if indicated)
- Airway obstruction: Bronchitis from Flu A and H1N1
- Gas exchange failure
- Heart failure
- Pulmonary edema
- Respiratory tract infection: Flu A and H1N1
Clinical Signs and symptoms
- Altered mental status: upon admission to the ED in Altaview
- Use of accessory muscles
- Tachypnea
- Cold, clammy skin: upon admission to the ED in Altaview
- Wheezing
- Crackles
- Tachycardia
- Other symptoms that the patient did not display
 o Ashen skin
o Asymmetrical chest movements
o Cyanosis
o Pursed lip breathing
o Increase/decrease tactile fremitus
o Hyperresonance
o Diminished or absent breathing
o Asterixis
o Myoclonus or seizures
Complications
- Tissue hypoxia
- Pulmonary embolism
- Barotrauma
- Pneumonia
- Hypotension
- Arrhythmia
- Acute MI/cardiac arrest
- Endocarditis
- Pericarditis
- Stress ulcers
- Chronic respiratory acidosis
- Metabolic alkalosis
- Respiratory arrest
- Acute kidney injury
Treatment regimen
- Treat the underlying reason causing the acute respiratory failure
o Treat pulmonary edema – diuretics
o Treat pulmonary HTN – antihypertensives
o Treat respiratory infections – antivirals for the flu A and H1N1
- Noninvasive positive pressure ventilation: BiPAP
- Intermittent or continuous noninvasive positive pressure ventilation: BiPAP
- Venous thromboembolism prophylaxis in hospital: heparin 5,000 unit every day
- Other
o Mechanical ventilation; High-frequency ventilation if patient doesn’t respond to
conventional mechanical ventilation