Tommy Keller

October 13, 2018

NUR 453

Clinical Journal #2

This clinical journal will exam a day on floor 4 medical surgical unit at Jackson North

Medical Center. The day began with our clinical instructor teaching us about the importance of

practicing good technique and staying safe while we were under the supervision of our nursing

preceptors. He discussed the importance of knowing our patients and the care that they needed as

well as gathering said information personally and not relying on other people. Our instructor

explained that by relying on the chart or other people’s assessments we weren’t truly getting a

picture of the status/condition of our patients. He went on to explain that we must do our own

thorough assessment to get a clear picture of what’s happening. Just knowing enough to push

meds is not our job, we need to understand the entire picture of what is happening with each

individual patient.

The patient that I chose to focus on was a 68-year-old male that was admitted

complaining of pain in both of his feet. The patient reported that he had a history of

hypertension, diabetes mellitus, and HIV. He denied any use of substances, stated he drank

socially, and stated that he smoked over 10 years ago but hasn’t smoked since except on the

rarest of occasions. The patient denied having any advanced directives and reported that he was

allergic to lisinopril but did not specify as to the reaction that occurs. Patient had a 20-gauge

peripheral IV saline lock in his right hand dated 10/06/18 and was NPO due to his plan of care in

which he was scheduled for surgery. It’s important to note that his plan of care was delayed
because on the previous day he was scheduled for an angiography of the lower extremities at 9

am but was pushed back 6 hours due to unforeseen circumstances in the emergency department.

The patient was awake, alert, and oriented to person, place, and time. Patient ambulates

with assistance. His pupils were equal, round, reactive to light, and accommodating. S1 and S2

heart sounds were present, pulses were 2+ in all extremities bilaterally, and heart rate was within

normal limits and regular. Patient had equal chest expansion, breathing was unlabored, and had

clear breath sounds bilaterally. Patient’s abdomen was soft, non-distended, and bowel sounds

were found in all 4 quadrants. Patient was on an 1800 calorie ADA diet. Patient reports last

bowel movement was formed and that he voids normally. Patient reported last urination was pale

yellow. Patient’s skin was intact except for his feet which had wounds bilaterally. Patient

reported decreased sensation in extremities, but his pulses were 2+ bilaterally. Patient was

scheduled for a surgical procedure to debride and irrigate wounds, which he signed all consents

for. Surgeon elected to push back surgery based on his renal function lab findings which were

outside normal limits.

Patient takes Humalog, a rapid acting form of insulin to lower his blood sugar. A

common side effect of this medication is low blood sugar. He takes Lantus, a long-acting insulin

which helps keep his blood sugar within normal limits. Lantus side effects are also similar to

hypoglycemic symptoms, such as headache, sweating, shakiness, and anxiety. He takes etravirine

to decrease the viral load of HIV in order to prevent infection. Side effects of this med are

nausea, weight loss, and joint pain. The patient takes darunavir, a protease inhibitor to keep the

viral load low in his body. Side effects of this are nausea, vomiting, dark urine, and jaundice. The

patient takes Plavix, an antiplatelet to prevent heart attacks that is indicated by his history of

hypertension. Side effects of Plavix are itching, bruising, bleeding, and rashes. The patient takes
amlodipine, a calcium channel blocker to keep his blood pressure low. Side effects of this

medication are headache, edema, and dizziness. He receives Tylenol PRN for acute pain related

to the ulcers on his feet. Side effects of Tylenol are nausea, stomach pain, and dark urine. He also

takes Lipitor and pravastatin, statins, that help lower LDL’s and triglycerides to lower

cholesterol. Side effects of these are rhabdomyolysis, confusion, fever, and increased thirst.

Patient’s vitals were BP: 140/96, T: 97 degrees F, HR: 93 bpm, RR: 18, and PO2: 95%.

The patient’s lab results were: Na 136, Cl 99, Ca 9.7, BUN 80, Glu 200, K 4.3, CR 10, WBC 4.0,

PLT 300, HCT 40.0, HgB 12.0.

Upon discovery of the patient’s renal function related to BUN being 80. The surgery was

postponed until his renal function could be properly assessed. We immediately went to the

patient’s room and explained the importance of when he next urinates that he collect it in his

urinal and call the nurse and I. In order to advocate for this patient we called podiatry and renal

consults to find out more about why his renal indicators were so outside of normal limits. The

nurse and I used critical thinking and asked the patient about any other symptoms related to his

renal function. We asked if there were any changes in his urination pattern, color, smell, or

ability to urinate, in his recent history, which he denied. We also asked if he ever had any

feelings of shortness of breath or fatigue, and we asked if he ever noticed any chest pain. The

patient denied but also stated that he doesn’t exercise much and always feels tired when he

moves around a lot.

A priority nursing diagnosis for this patient is impaired skin integrity related to improper

management of Diabetes diagnosis as evidenced by skin and tissue color changes and pain. In

order to care for him it’s important that the nurse assess pain level and description every four

hours related to skin breaks, promote wound healing measures, and promote blood flow to
affected areas. It’s also important to note and document changes in classifications or

presentations of ulcers. A second diagnosis is risk for infection related to compromised host

defenses: HIV diagnosis as evidenced by low WBC count. The nurse must carefully monitor

WBC count, changes in mental status, and assess the wounds themselves for signs of infection

every four hours. It’s also important that we follow standard infection control precautions and

encourage and monitor patient for appropriate infection control measures. A third diagnosis for

this patient is ineffective therapeutic regimen management related to Diabetes Mellitus

management as evidenced by skin breakdown, pain, and uncontrolled glucose levels in blood.

This patient would benefit from being re-educated about his medical situation and how to control

his blood glucose levels. It’s also important to explain the benefits of being strict in glucose

management as described in “The Diabetes Control and Complications Trial.” This trial tested

the effects of normal glucose control measures against “tight” control measures which indicated

frequent blood glucose checks and keeping blood glucose between 80 and 140. The results of the

trial found a significant decrease in complications associated with diabetes (DCCT, 1987).

The nurse and I also had 3 other patients to care for. We were assigned to a 74 year old

male who had been admitted over 200 days prior. This patient had 5 skin wounds that needed to

be frequently assessed and was unable to feed himself, which took a lot of extra time to perform.

This patient was AAOX2 and required medications to be given with thick liquids to avoid

aspiration. His plan of care was stagnant and required constant wound attention because his

wounds were developed in the hospital and no other facilities would accept him in his current

state. We also cared for a 36 year old male admitted by police for alcohol abuse and was under

the Baker Act. This patient was extremely shaky and irritable due to the alcohol withdrawal. He

had a history of alcohol abuse, marijuana abuse, and bipolar disorder. His course of stay was
predicated on his CPK levels because he was diagnosed with rhabdomyolysis due to the alcohol

abuse. He would be discharged once his CPK levels returned to normal. The final patient we

cared for was a 56 year old male who was a frequent flyer on this unit. He was admitted for acute

psychosis, and had a history of non-specified psychosis. His hands were restrained with two

clubs to assure he wouldn’t scratch or harm himself. He was AAOX1 and required complete

management of care and ADL’s. It was found in case management meeting that he received

placement in a total care facility, which he would be discharged to by the end of the day.

My personal strengths for this day were assessing all the patient’s in a timely manner and

helping with case management meeting by knowing information about patients. During the case

management meeting we were asked about all of our patients and what the plans of care were.

When it came to a particular patient, the case manager asked what his CPK was and my nurse

didn’t know but I had already checked the chart and was able to give the case manager the

number. A problem that was seen on this unit was that there was very poor communication and

team work related to CNA’s and sitters taking breaks. At one point a sitter “needed” to take a

break and the nurse and I had to stay in that patient’s room until the sitter returned. He also

returned later than he was scheduled causing a delay in care.

“Diabetes Control and Complications Trial (DCCT): Results of Feasibility Study. The DCCT

Research Group.” Diabetes Care, vol. 10, no. 1, Jan. 1987, pp. 1–19.,

doi:10.2337/diacare.10.1.1.