FOCUS OF CARE WORKSHEET _ Course:_NURSING 240__________Clinical Instructor: _Professor Lane____________ Grade: ________

CODE STATUS: Full ACTIVITY: Bedrest DIET: Tube feedings (additional) + minced and moist diet ALLERGIES: NKA
STUDENT NAME: Tatiana Ageev
(5 POINTS)
Age & Development Stage: 40y.o. PATHOPHYSIOLOGY (20 POINTS) PLAN OF CARE (30 POINTS)
Generativity versus stagnation
Admission Date: 01/31/22 (came from According to Hinkle and Cheever (2017), Problem #2: Impaired Gas Exchange r/t Acute hypoxemic
subacute) pneumothorax is an accumulation of gas in respiratory failure AEB SOB, tachypnea RR 26, coarse
the pleural cavity. It leads to a collapse of crackles in all lobes, pt is constantly desatting to 80s, pt is
Patient Care Date: 03/11/22 the lung tissue, displacement of the on continuous aerosol FiO2 50% flow 12 (was previously
mediastinum to the healthy side, intubated), Chest tube in place, pt states “I have problems
Admitting Dx/Current Dx: SOB/ Large left compression of the blood vessels of the with breathing”
pneumothorax mediastinum, descent of the dome of the
diaphragm, which ultimately causes a
disorder in the function of breathing and
blood circulation. With pneumothorax, air
HPI: Prolonged admission from 12/13/21- can penetrate between the visceral and
01/27/22 with perforated viscus s/p parietal pleura sheets through any defect
subtotal colectomy and end ileostomy with on the surface of the lung or in the chest.
post-op septic shock and respiratory The air penetrating the pleural cavity
failure. AKI, required HD (came out of it causes an increase in intrapleural pressure
later), bil LE DVT, PE, s/p IVC filter, trach (normally, it is lower than atmospheric
and PEG tube 01/17/22, lack of appetite, pressure) and leads to a collapse of part or
malnutrition. H/o cardiac arrest, intubation the whole lung (partial or complete
12/23/21. H/o Resp failure. Abnormal EEG collapse of the lung).
on 01/05/22.

Goal: Patient maintains clear lung fields and remains free of

signs of respiratory distress by the discharge.

PMH: Crohn’s disease (discovered in June Interventions/Teaching:

2021-tx Humira), anxiety, migraines, iron 1. Nurse will position patient with head of bed elevated,
deficiency due to chronic blood loss, h/o in a semi-Fowler’s position (head of bed at 45
smoking x13 y. ago from 06/23/20 degrees when supine) as tolerated.
2. Nurse will regularly check the patient’s position so
Sx: 06/14/21 Colonoscopy that he does not slump down in bed.
09/11, 01/12, 04/12 pr removal GB 3. Nurse will turn the patient every 2 hours. Monitor
mixed venous oxygen saturation closely after
turning. If it drops below 10% or fails to return to
baseline promptly, turn the patient back into a supine
position and evaluate oxygen status.
4. Teaching: Nurse will teach patient deep breath and
perform controlled coughing. Have patient inhale
deeply, hold breath for several seconds, and cough
Social/family/occupation/impact on illness: two to three times with mouth open while tightening
the upper abdominal muscles as tolerated
Lives in a home. Married. Wife and
daughter at the bedside. Nurse. Illness has
a huge impact on a lifestyle. Prognosis-
unknown.
Current Vital Signs: T 97.6 axillary, P 96,
RR 26, BP 122/77 R Arm, MAP 94, Pulse Ox
94% on FiO2 50% flow 12 continuous
aerosol, pain 0/10
KEY ASSESSMENT (10 POINTS)
Assess for: Actual Findings:
Pulmonary Tachypnea, RR 26,
shallow breathing,
mechanical device, no
use of accessory
muscles, no retractions,
expansion symmetric,
thin white secretions-
trach. All fields: coarse
crackles, diminished
lung sounds. Chest tube-
(rt) zero drainage, no air
leak.
Abdomen Abdomen is flat, non-
What are your patients’ risk factors?
-infection
-ileus
-anatomical predispositions
-respiratory distress
-bedbound
-h/o cardiac arrest
-mechanical ventilation/continuous aerosol
According to textbook(s), what is the
treatment for the present illness?
According to Hinkle and Cheever (2017),
The treatment of pneumothorax includes
needle aspiration, chest tube insertion, and
surgery.
What is currently being done to treat the
present illness?
Chest tube is inserted
IV fluids
94% on FiO2 50% flow 12 continuous
aerosols
RT: Breathing treatments
LABS/DIAGNOSTIC TESTS (10 POINTS)
Problem #2: Risk for imbalanced nutrition related to lack of
appetite, malnutrition.
Goal: The patient will achieve an adequate nutritional status,
as evidenced by stable weight or weight gain by the
discharge.
Interventions/Teaching: Nurse will:
1. NW Assess skin integrity and wound healing.
2. NW Measure intake and output accurately; Monitor
weight daily; Monitor calorie counts, including
calories provided by tube feedings
3. NW Administer the prescribed rate of Tube feeding
solution via an infusion pump.
4. NW Refer to dietitian or nutritional support team.
5. Teaching: Nurse will educate the pt about the
necessity of maintaining balanced nutrition
EVALUATION OF EACH GOAL (5 POINTS)
1. Goal met. Patient maintained clear lung fields and
remained free of signs of respiratory distress by the
discharge.
2. Goal met. The patient achieved an adequate
nutritional status, as evidenced by stable weight or
weight gain by the discharge.
 distended. Soft, tender
for palpation. 4
quadrants are
normoactive. BM-small
watery, no solid
pieces-green. Ostomy
(R abdomen)-pink,
round. PEG tube no
s/s of infection.
Nutrition at rate
45ml/hr
Cardiac S1 S2. SR. Pedal and
radial pulses are strong
and equal. 2+. BP 122/77.
Integumentary: Skin dry, warm.
Coccyx wound-dry
intact reddened, pink.
Clean. Dressing
applied. No tingling.
No discoloration.
Extra
assessment:
Neuro A&O x4, PERRLA
x3mm, trached,
speaking valve use
Musculoskeletal: Muscles bil lower and
upper extr hypotonic,
weak. Purposeful
motor response. Hand
grip bil moderate,
dorsi and plantar
weak. Straight leg
raises bil moderate.
GU Uses urinal. Voids
spontaneously. Clear,
yellow.

Additional key labs/diagnostic tests:

WBC 9.7, Hgb 8.4, Hct 25.8
PT 17, INR 1.5, PTT 32, plt 446
Na 130, K 5.5 (on kayexalate), Cl 92, CO2 37,
BUN 33, Cr 0.39, Gluc 93, Ca 10.5, Mag 1.7

02/25/22 Blood gases: pH 7.31, PCO2 75,

PO2 56, O2 sat 87, HCO3 37.9, Hgb 9.8
02/27/22 UA- few bacteria in urine
02/27/22 blood cultures- Staph epidermidis,
Mrsa
01/31/22 CT abd- R pleural effusion. Bil
interstitial infiltrates. L pneumothorax.
Hepatomegaly. IVC filter. Edema anasarca.
Ascites. Ostomy RLQ.

02/03/22 CT Chest- R sided Chest tube with

large R sided pneumothorax and L sided
Chest tube with moderate pneumothorax.
Mild cardiomegaly.

02/22/22 CT Chest- Atelectasis with small

bilateral pleural effusion.

03/02/22 EKG -SR

03/02/22 Echo US – EF 50%, eccentric,

myxomatous MV disease. RVSP is moderate
elevated 49 mmHg

03/10/22 CXR – pneumothorax is resolving.

 MEDICATIONS (20 POINTS)

MEDICATION/CLASS DOSE, FREQUENCY, ACTION ADVERSE EFFECTS NURSING TARGET SYMPTOM

ROUTE  Describe the physiological IMPLICATIONS & EFFECTIVENESS
action  Specific for this
 Use your own words patient; why are
they receiving this
medication?
 How do you know
this medication is
effective? Include
specific data.
5-325mg tab Binds to mu receptors in -confusion -assess RR -pt is taking med for
PEG tube, q 4hrs the CNS. Alters the -sedation -assess for pain moderate pain
Hydrocodone PRN for moderate perception of and -hypotension -assess for constipation -E.: Unknown
Norco pain response to painful stimuli -constipation -assess level of Patient did not
T: opioid analgesics while producing -respiratory depression consciousness request pain
generalized CNS -assess risk for opioid medication during
P: opioid agonists depression. Helps to addiction, abuse, or my shift, pain level
decrease severe pain misuse prior to 0/10
administration
160mg/5ml liquid Inhibits formation of -HTN -Assess overall health --pt is taking med
650mg PEG tube, prostaglandins, that are -Hepatotoxicity status and alcohol for pain and fever
q4h PRN for pain responsible for pain -constipation usage before -E.: Unknown
and fever sensation and fever -renal failure administering Patient did not
acetaminophen production -muscle spasm acetaminophen request pain
T: antipyretics -ACUTE GENERALIZED -assess for other OTC medication during
nonopioid analgesics EXANTHEMATOUS drugs, containing my shift, pain level
P: Analgesic PUSTULOSIS, -STEVENS- acetaminophen 0/10. No fever.
JOHNSON SYNDROME, -assess for pain
-TOXIC EPIDERMAL -assess for fever
NECROLYSIS

325mg Treatment and prevention -dizziness, headache, -Assess nutritional Pt is taking it to treat
ferrous gluconate BID PEG tube of anemia syncope status and dietary low Hgb levels
Fergon -n/v, constipation, dark stools, history to determine Hgb 8.4, (Hct 25.8)
epigastric pain, GI bleeding cause of anemia E: Y
-Assess bowel function Hgb level on
for constipation and admission 7.8, Hct
Ther. Class. diarrhea 24.3
antianemics -Monitor Hgb, Hct

Pharm. Class.
iron supplements
 200mg PEG tube Osmotically active in GI GI: diarrhea -Assess patient for -My pt is taking it as
Magnesium Oxide 2xdaily tract, drawing water into abdominal distention, a laxative due to
Ther. Class. the lumen and causing Derm: flushing, sweating presence of bowel being bedbound
mineral and electrolyte peristalsis. sounds, and usual and opioid
replacements/supplements pattern of bowel prescription
laxatives function. -E: Y
- Assess color, No s/s of
Pharm. Class. consistency, and constipation
salines amount of stool
produced.

Eliquis 5mg PEG tube 2x Treatment and prevention Hemat: BLEEDING Assess patient for -to prevent blood
Ther. Class. daily of thromboembolic events. Misc: HYPERSENSITIVITY symptoms of stroke, clots due to
anticoagulants REACTIONS DVT, PE, bleeding, or immobility and h/o
INCLUDING ANAPHYLAXIS peripheral vascular DVT and PE.
disease periodically -E: Y
during therapy. No bloods have
formed since the pt
was admitted
Vancomycin 1500mg in saline Binds to bacterial cell wall, CV: hypotension -Assess patient for Pt is taking it to treat
200ml/hr IVPB IV resulting in cell death. Derm: rash infection (vital signs; bacteremia
Ther. Class. q12hr EENT: ototoxicity appearance of wound, E: Y
anti-infectives GI: nausea, vomiting sputum, urine, and WBC went down
GU: nephrotoxicity stool; WBC) at since the day of the
Hemat: eosinophilia, beginning of and admission from to
leukopenia throughout therapy. 15.1 to 9.7
Local: phlebitis -Monitor BP throughout
MS: back and neck pain IV infusion.
Misc: HYPERSENSITIVITY -Obtain specimens for
REACTIONS (INCLUDING culture and sensitivity
ANAPHYLAXIS), chills, fever, prior to initiating
"red man" syndrome (with therapy. First dose may
rapid infusion), superinfection be given before
receiving results.
-Observe patient for
signs and symptoms of
anaphylaxis
Lansoprazole 3mg/ml 30mg PEG Binds to an enzyme in the GI: CLOSTRIDIOIDES Assess patient routinely -Pt is taking it to
Ther. Class. tube daily before presence of acidic gastric DIFFICILE-ASSOCIATED for epigastric or protect his stomach
antiulcer agents breakfast pH, preventing the final DIARRHEA (CDAD), abdominal pain and for lining.
transport of hydrogen ions diarrhea, abdominal pain, frank or occult blood in -E:Y
Pharm. Class. into the gastric lumen. fundic gland polyps, nausea stool, emesis, or gastric -No pain and s/s of
proton pump inhibitors GU: acute tubulointerstitial
nephritis
Hemat: vitamin B12
deficiency
MS: bone fracture
Neuro: dizziness, headache
Misc: HYPERSENSITIVITY
REACTIONS (INCLUDING
ANAPHYLAXIS,
ANGIOEDEMA, OR ACUTE
TUBULOINTERSTITIAL
NEPHRITIS), systemic lupus
erythematosus
Midodrine 5mg PEG tube Activation of alpha-1– CNS: anxiety, confusion,
Ther. Class. q6hrs Hold for SBP adrenergic receptors in head pressure/fullness,
vasopressors >120 arteries and veins. headache, nervousness
CV: supine hypertension,
bradycardia
GU: urinary
urge/retention/frequency,
dysuria
Derm: facial flushing,
piloerection, pruritus, rash
Neuro: paresthesia
Misc: chills, pain
aspirate. gastric ulcers seen
Monitor bowel function.
Diarrhea, abdominal
cramping, fever, and
bloody stools should be
reported to health care
professional promptly as
a sign of Clostridioides
difficile-associated
diarrhea (CDAD). May
begin up to several wk
following cessation of
therapy.
Monitor supine and -Pt is taking it to
sitting BP prior to and treat low BP.
during therapy. -E:Y
Assess pattern of -BP raised from
urinary output prior to 98/65 in the
and during treatment for morning to 122/77
incontinence. after administration