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Clinical Updates: Email Template

Student name: Date of care provided:

Patient assignment:

 Briefly state your patient assignment numbers and their diagnosis.

1. Mr. S.J : Sepsis 59 Yrs Old DNR( only in event of cardiac arrest) with full medical
treatment.
2. D,K : ALC 22 Yrs old Full Code
3. J,V : Dermatitis 31 Yrs old Full Code
4. E, A : COPD – end stage 70 Yrs. DNR with full medical treatment
Provide examples throughout your clinical updates of how you utilized critical thinking and
analysis of the information collected to meet the expectations outlined below. Correlate
findings and provide rationales to demonstrate of knowledge.

Clearly indicate which ONE of your patients from the above list and discuss the following:

A. What is their admission diagnosis – briefly describe what brought patient to hospital and
demonstrate your understanding of the diagnosis. (Application of pathophysiology)

59 years old male presented to emergency services for upper left quadrant pain and send home without
any diagnosis. Patient had recurrent visit to emergency department but medical professionals were
unable to establish a diagnosis and was sent home every time. Patient was admitted to emergency
services with anasarca with hypoalbuminemia. During hospital stay patient development different
complications that prolonged his stay in the hospital and has been residing at my placement unit since
March, requiring continue nursing care. Patient has very extensive history, I will explore his current
conditions in detail in under his current medical condition.
What is current medical condition - if different than admission –

Patient’s current medical conditions are as follow

1. Urinoma Secondary to left upper perforation with a nephroutero stent in situ: Patient developed left
upper quadrant pain and flank pain in upper left side of his back. Pain was radiating to his lower left
back.After extensive diagnostic studies, patient was diagnosed with multiple stones in his left
kidney. Spring this year patient developed septic shock from urinary obstruction. Perforation of the
ureter is a rare condition that causes a series of problems including retroperitoneal urinoma. Patient
was treated with retroperitoneal fluid collection secondary to the ureteric perforation. The fluid grow
candida and he was on fluconazole. The infection has been cleared and antibiotics has been
discontinued. Insertion of Foley catheter, nephrostomy tube (left side), and percutaneous drain ( left
side) was done to resolve this complication and facilitate urine output.
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2. Diffuse large fiber sensory motor anoxal polyneopathy : Patient is bed bound since his admission
due to his new diagnosis and requiring hoyer left transfer from bed to geri chair. There was no notes
to indicate why patient developed this complication during his stay at hospital. I did extensive
research of his past medical history but unable to obtain any solid reason for this diagnosis.
3. Tracheostomy: Due to septic shock patient was mechanically ventilated and was transferred to ICU.
Patient was unable to wean off from his tracheostomy in ICU and needed frequent suction and
nursing care. The goal is to discontinue tracheostomy tube once patient is able to manage his
secretions. At the moment patient is on room air via trach mask.
4. PEG tube feeds: Suffers from dysphagia and has had a PEG tube for a year. Barium Sallow test was
done repeated. .SLP noted the unusual finding of no sphincter relaxation to the degree that none of
the food and even none of the secretions entered the esophagus at all. All secretions were actually
going into lungs. This was one of the rational for patient having thick secretions through his
tracheostomy site and needed frequent suctioning to clear his airway.
5. Diabetes mellitus type 2 on insulin: Patient was diagnosed with diabetes in emergency department.
Patient is permanent landed immigrate to Canada and landed last year. He did not have any blood
glucose test done in the past to screen his risk for diabetes. Infections tend to increase blood glucose
levels and this was also one of the contributing factors in his case.
B. Co-morbidities/past medical history – indicate knowledge of significant ones listed.

1. Nephrolothiasis : Nephrolithiasis specifically refers to calculi in the kidneys, but renal calculi and
ureteral calculi (ureterolithiasis) are often discussed in conjunction. The majority of renal calculi
contain calcium. The pain generated by renal colic is primarily caused by dilation, stretching, and
spasm because of the acute ureteral obstruction. Patient has history of renal obstruction related to
stone in left kidney.
2 Right inguinal hernia repair: An inguinal hernia occurs when tissue, such as part of the intestine,
protrudes through a weak spot in the abdominal muscles. The resulting bulge can be painful, especially
when you cough, bend over or lift a heavy object. Patient used to work as a farmer and use to lift heavy
objects and dong heavy lifting work. Another cause for developing right inguinal hernia is heavy lifting
causing straining on the muscles.
3 Anasarca with hypoalbuminemia: Patient developed anasarca due to his impaired kidney
function and obstruction. When kidney function is impaired, fluid is not removed from the body
adequately, which can cause anasarca. Accumulation of fluid may occur due to any illnesses and
conditions that change the proteins of the body, affect the balance of fluids, or create abnormalities in
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the blood vessels or lymphatic system. Albumin is a protein made by the body that is necessary for
a variety of important functions, including balancing fluid. In cases of poor nutrition and certain serious
medical conditions, the level of albumin can become too low. When this occurs fluid from the
bloodstream is pushed out into the tissues causing swelling. In some cases, replacing albumin can help
correct this problem.
4 Neurogenic bladder: diagnosed in his country of birth. Neurogenic bladder is bladder
dysfunction (flaccid or spastic) caused by neurologic damage. Symptoms can include overflow
incontinence, frequency, urgency, urge incontinence, and retention. Risk of serious complications (eg,
recurrent infection, vesicoureteral reflux, autonomic dysreflexia) is high. Diagnosis involves imaging
and cystoscopy or urodynamic testing. Treatment involves catheterization or measures to trigger
urination. Previous history of ureteric stents inserted and removed in country of birth
5 History of hypercapnia respiratory failure requiring tracheostomy last year.
6 Hepatic steatosis- Non-alcoholic fatty liver disease, defined as the presence of macrovascular
steatosis in the presence of less than 20 gm of alcohol ingestion per day. It is most commonly associated
with insulin resistance/type 2 diabetes mellitus and obesity.
`7 Right arm DVT : Prolonged bed rest, such as during a long hospital stay, or paralysis.  Patient is
on bed rest in hospital. Patient is on Dalteparin Sodium 2500 mg Hs to avoid complication of DVT.
8 Recurrent pleural effusion: A pleural effusion is an unusual amount of fluid around the lung. History
notes indicate that patient developed this due to his anasarca and septic shock
C. Social history – where does patient come from (home, nursing home etc), and who is their
support system?
Patient landed in Canada two years ago November and lives with his wife. He never worked in Canada
and does not speak English. Patient has 5 children, one of them lives in Canada and rest of his four
children lives outside of Canada. His wife is very dedicated to his care and involved in his medical
decision making. She has not left patient’s bedside since his admission and stays with patient
24/7.Family does have hard time to cope with patient’s functional decline and health conditions. There
was multiple meeting held by health care professional to discuss patient’s goals of care and suggesting
palliative approach because patient’s condition continue to decline during his hospital stay and requiring
recurrent admission to ICU. Wife refused to send patient to nursing home and believes that patient can
return to his house on his feet. Medical professionals notes indicate that family is unable to comprehend
that patient will not walk again or gain his baseline function. Patient’s wife does not speak English but
able to advocate for patient through interpreter.
D. Priority nursing assessments- indicate your priority systems assessed –indicate findings
and provide rationale for whether abnormal or normal. You should have at least 3 priority
systems related to specific health issues and provide rationale why chosen (PLUS Pain as
required) (Health Assessment)\Vital Signs and indicate trend for patient – acknowledge if vitals
abnormal.
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1. Vital signs :BP: 122/83 PULSE: 70, T: 36.5 ,O2SAT : 93% @ room air via trach mask ( room air

from wall), RR: 17, Pain: 0/10

2. Respiratory system: Patient was received lying in bed alert and oriented, able to speak small
sentence. Patient verbally denied any respiratory distress. During assessment Tracheostomy site did
not have any signs of infection, Stoma was not swollen, frothy sputum noted on trach dressing.
Humidification attached to trach tubing. In artificial airway natural humidification is bypass.
Humidification decreases the chance of thick sticky secretions (mucus plugs) which are hard to
suction and may block the air passage.
Upon auscultation of lungs Bilateral Adventitious lung sounds heard upper and lower lobes–
crackles and wheezy .Noted mucus (thick mucus secretions) on trach dressing, no sign of blood
noted. No use of accessory muscles noted. Patient was on uncuffed tracheostomy tube. Uncuffed
tracheostomy tube does not have a ballon which is inflated with air to seal the airway. Uncuffed
tracheostomy tube is used for patient who are able to protect their own airway when swallowing and
coughing. Patient is on shiley #7 disposable cannula.
Interventions required:

 Suctioning: I washed my hands and gathered tracheal suctioning kit which includes sterile disposable
gloves, sterile water cup, disposable suction catheters, and wall suction. I filled clean disposable cup
with sterile distilled water. Adequate flow of suctioning and attached white thumb side if the suction
catheter to the suction tubing. I was careful to not contaminate the opaque portion of the catheter. I
changed my clean gloves again being careful not to touch anything but catheter. I withdraw catheter
from package slowly and held sterile opaque portion of the catheter 10-15 cm from the tip. I dipped
catheter into saline water and aspirated a small amount of fluid to lubricate it and test suction by
occluding thumb control valve. Patient was alert and awake during this intervention and allowed me to
perform suction. I removed trach mask from trach site and inserted catheter into tracheostomy tube
gently without applying suction. Once I met resistance, I withdraw the catheter 1-2 cm. I applied suction
by occluding thumb control valve intermittently and withdraw the catheter while gently rotating catheter
between fingers and thumb. I dipped catheter into distilled water and aspirated to clean catheter. I
applied trach mask on patient after completing suction. Patient’s oxygen saturation improved to 94%
liter via trach mask on room air. I suctioned patient 3 times during my shift.
Patient’s wife is allowed to suction him but I noticed during my shift that she did not wear sterile
gloves and did not maintain sterile field during trach suction. Since, I was able to speak same
language as patient, I was able to educate patient’s wife to maintain sterile field to avoid any
further complications related to infections. On my second observation, I noticed wife was using
sterile gloves and maintained sterile field.
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Trach dressing change was done because patient was having thick mucus on dressing and it is
important to keep tracheostomy area clean and dry to avoid infections. I wore clean gloves and removed
trach dressing. I wore sterile gloves to clean trach site with hydrogen peroxide, applied trach dressing
gauze. Patient tolerated this procedure well.
 Changed disposable inner cannula: Patient was on disposable inner cannula shiley # 7. During my
shift i noticed that secretions were very thick and blocking the inner cannula. I changed patient’s
inner cannula safely. Patient tolerated procedure well.
 Trach mask: I changed patients trach mask because previous mask had secretions on it. I was able to
tie trach mask successfully. I did not touch trach ties during this process because only RT is allowed
to touch tracheostomy ties.
 Mouth care: patient was NPO via mouth .I noticed that patient’s mouth was dry and needed
lubrication. I provided oral care to patient to maintain moisture and avoid skin break down.

3. GI /GU assessment: Upon auscultation bowel sounds heard in all four quadrats. Abdomen was flat and
non-tender to touch. Peg tube site appears clean and dressing was intact. Peg tube was running via
pump, I held peg tube feeding during am care. I flushed peg tube with 30 cc water to avoid accumulation
of feed to occlude peg tube and clamped it, Patient was incontinent of large amount of stool. I provided
incontinent care and assessed patient’s skin for breakdown. Patient’s wife requested to stay with patient
during am care and I was more than happy to have patient family involved in care. Patient and his Wife
was aware that I am student registered nurse .Patient was able to turn to his sides with one person assist,
but wife remain with patient during care to assist his turns.
Interventions:

 Continue feed (Initial checks): Patient was on continues peg tube feed at 65 cc/hour via pump,
require 300 cc flush Q3hr via pump. Pre and post medication flush 30 cc. I checked settings on
feeding pump to make sure patient was receiving right about of feed and flush. Setting were
accurate on pump. I also checked type of feed Isosource 1.5 high fibre and documented in
computer my findings. Patient’s head of bed was at 45% angle and it was appropriate for tube
feeding.

 Dressing and skin assessment: wife was present during this procedure, and patient also
requested wife to stay by bedside. I removed old dressing, no gastric leakage or redness or
swelling noted at tube insertion site. Cleansed site with Normal saline as instruction were given
on patient chart. New dressing applied and secured with medipore tape.

 Nephrostomy tube dressing and percutaneous tube –left side: I confirmed order in patient
chart for Q3day dressing change. I assisted patient to lie on opposite side of nephrostomy
tube/perc. Tube site. I placed disposable sheet under patient and wore PPE. I washed my hand
before performing dressing change. I removed old dressing and noted old dry secretions on
abdomen pad. Redness around nephrostomy site and percutaneous site noted, due to irritation
from tube ports. No swelling or leakage from nephrostomy or prec. Site noted. I applied
polysporin as ordered in MAR around nephrostomy and prec. Site. I emptied patient’s
nephrostomy nag before performing dressing change and output was 300 cc at beginning of shift.
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Perc tube output was 10 cc. Previous history notes indicate patient’s percutaneous tube will be
removed in coming week because there was fluid accumulation noted.

 Medication admistration via Peg tube: Pre and post flush was 30 cc , I followed physicians
order for medication administration. I crushed medication and dissolved it inside warm luke
water, head of the bed was maintained at 50% angle. Patient was on medication every two hours

 Foley catheter: Patient Foley catheter was intact 16 F, Clear yellow urine was draining inside
the bag. Patient urine output was 700 cc during my shift. There was no foul smell to urine. Site
of Foley insertion was intact and there was no sign of infection noted. Patient urine output was
satisfactory.

4. Extremities Integumentary: patient was unable to lift his arms or legs due to his neuropathy.
Patient was on prolonged bed rest. Skin to upper and lower extremities was intact and moist. PICC
line to right upper arm. Patient was on antibiotics Q6H via PICC Line and PUMP.I flushed PICC
line with NS 10 cc pre and post mediation administration (order in chart).I also checked placement
by aspirating fluid from PICC line before medication administration and flushed it with normal
saline. My preceptor was present during my first two doses of administration of antibiotic to guide
me and directly observe me. I directly observed my preceptor during PICC line dressing change.
Measurement of PICC line done , arm circumference = 22 cm ( same as pervious readings) , Picc
line externa length = 12 cm ( same as pervious reading)

Interventions:

 Up in the chair for two hours daily via Hoyer lift: I attached oxygen tank to geri chair and
attached trach tube to O2 tank at 2lit. Patient O2 saturation was 99 % at 2 Lit. Oxygen via trach
mask. Peg tube was flushed and clamped for two hours. Nephrostomy tube, Foley catheter and
perc. Tube drains were emptied to avoid any strain. Patient was suction before transferring to
geri chair, consent was obtained for procedure.

Lab Values –relate significant lab values to current diagnosis/medical condition and provide rationale
as well as any significant concerns.
No recent lab result, most recent labs were done

Na: 137 normal

Cl: 102 normal
Potassium: 4.2
Creatinine: 77
Calcium 2.28
Phosphorus: 1.26
Magnesium 2.28
Totyal bilirubin 54
ALT 9
AST 22
Albumin 25 –low – previous results in same range
WBC 8.0
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RBC 4.5
Hgb 126
Plt 339
MRSA- Nagitive
VRE – Nagitive

Diagnostics – incorporate knowledge of significant diagnostic findings to current diagnosis/medical

condition. Ex: Pneumonia – chest x-ray indicates pneumonia.
No recent diagnostic studies were done, patient is residing at same unit from over a year and no

Diagnostics were done recently at current hospital.

Medications: List all scheduled medications for this patient and relate to patient’s current condition or
to a past medical/health history condition when applicable. (Pharmacology)

All oral meds via peg tube

Acetaminophen 650 mg TID VIA PEG TUBE

Meropenem 500 mg IVABx/PICC Line Q6Hr patient had left sided collection that is urine leaking in his
ureter. Patients urinary tract is being fully decompressed with a catheter , nephrostomy tube and percutaneous
drain. Antibiotics were started to reduce the risk of bacteria growth.
Pancrelipase 4 tabs Q4Hr: helps with digestion. Patient has history of kidney stones and was at risk for
pancreatitis
Artifical Saliva TID : to avoid dryness in mouth
Clotrimazol 1% cream PRN Pt developed diaper rash in the past , resolved now
Dalteparin 25 unit once Hs Pt is at bed bound and at risk for developing blood clots , PMHx of DVT
Escitalopram 5 mg Once : Used for anxiety and depression.This medication was added on family request
because family felt patient is developing depression due to his prolong stay in the hospital.
Hydrocortisone 15 Mg at 0800 glucocorticoid treatment is associated with significant improvements in patients
with severe pneumonia or acute respiratory distress syndrome. Patient had recurrent admission to ICU due to
his respiratory failure during hospital stay. His baseline PCo2 is 40.Another reason for this medication
admiration was because patient has adrenal insufficiency.
Hydrocortisone 5 mg at 1600
Insulin Humulin N 10 units BID SC : to manage diabetes. Patient is on schedule dose of corticosteroids and
one of the side effect of this medication is increase in blood glucose levels. Insulin isophane is an intermediate-
acting insulin that starts to work within 2 to 4 hours after injection, peaks in 4 to 12 hours, and keeps working
for 12 to 18 hours. ***
Insulin Lispro ( Humalog) QID Sliding scale SC : is a rapid-acting human insulin.
Midodrine HCL 10 mg TID : Patient has history of anasarca , which lowers blood pressure. Midodrine is being
used to manage patients’ blood pressure successfully.
Communication:

a) Indicate any unique or special communication techniques for this patient.

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Patient and his wife had language barrier and needed interpretation. I was able to speak with
patient in his native language.
b) Describe patient teaching performed and patient/family response.

 I educated patient’s wife about good hand hygiene and maintaining sterile technique when
performing suctioning.
c) Indicate any collaborated communication with health care team (daily rounds, physician etc)

d) During physicians round I was by patient bedside .As per physician patient look dehydrated despite
getting frequent 250 cc q3hr water flush via peg tube .Physician increased peg tube flush between
feed at 300 cc Q3hrs.Collaborated with RT and changed inner cannula
e) Describe your therapeutic relationship with this patient/family.

I provided patient- centered and family- centered care to patient .I followed patient and his
family recommendations related to care and provided autonomy to patient. I understood my
patient’s abilities and limitations. I understood patients wife’s role in his care to achieve best
health care outcome for my patient.
f) What are the barriers to discharge and what is your role to ensure discharge process is
completed?
 Patient’s family wants patient to go home but patient requires continues nursing care related to
his tracheostomy, nephrostomy and ambulation. Patient has a trend of getting stable and
bouncing back to ICU r/t to his recurrent renal complications.
Ethical/Legal Issues:

 Provide an example of how you advocated on behalf of your patient. Remember every time you
perform an intervention, administer medications, send patients for a test there are ethical and legal
issues involved. Who is patient POA, are they DNR, have they consented to a test, did you provide
information about tests or treatments so they can make informed decision?

Patient’s family doesn’t want patient to go to a nursing home and refuse to leave the hospital. Despite
many family meeting, family resist that patient is capable to go back to his baseline function and
physician should consider removing the Peg tube. Recent barium swallows study shoes that patient has
no control over his swallowing and all food was directly going into his lungs. This also explains the
reason for patient to have recurrent upper respiratory infections. Patient has right to receive care and
decide his goals for treatment. Most responsible physician understands and agrees with patient’s family
and providing continues treatment.
 Did you observe any ethical/legal concerns regarding this patient? If so, what ethical principle
was most applicable?
- Fairness : it is important to provide equal attention to clients despite their needs .This patient needed
prioritization of task and one on one nursing care.

- client choice: Even though health care team wanted patient to reconsider his code status but it is
patients choice to decide what is best for him.
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- Respect for Life: As a health care team member, it is our responsibility to understand patients value
toward life and continue to provide quality of care.

Self-Reflection: Reflect on your nursing practice progression.

1. Your progress of competencies and learning plan goals.

I met all my competences and learning goals.

2. Identify and describe one nursing theory you have implemented into your nursing practice (from

Knowing through Inquiry class) for your selected patient

Madeleine Leininger: One of the newer nursing theories, Transcultural Nursing first appeared in 1978.

According to Leininger, the goal of nursing is to provide care congruent with cultural values, beliefs,
and practices. Leininger states that care is the essence of nursing and the dominant, distinctive and
unifying feature. She says there can be no cure without caring, but that there may be caring with curing.
Health care personnel should work towards an understanding of care and the values, health beliefs, and
life-styles of different cultures, which will form the basis for providing culture-specific care.
I identify importance of patient’s cultural values and beliefs and respected their wishes. I familiarize
myself with patient’s religious beliefs and understood patients beliefs can help him to recover and gain
emotional strength.
3. Identify one or more Caritas Process that you have implemented into your care for the patient you

have selected

- Being authentically present, enabling faith/hope/belief system; honoring subjective inner, life-world
of self/others.
- Developing and sustaining loving, trusting-caring relationships.

I focused my care around Second and fourth caritas process. Patients and his wife did prayer multiple
times during day and I respected their space and values. Patient’s wife use to say prayer out loud near
patient, when I use to provide care to patient. I respected their belief system and build trusting- caring
relationship with patient and his family.

4. What did you do well?

I was able to manage patients care independently. I communicate my concerns with MRP when I
doubt about any order and also provide safe care to my patient. I was able to meet my learning goals
by prioritizing my task and managing tracheostomy care.
5. What is an area for improvement and how will you implement Strategies for this?

I will continue to practice my skills.