YOUNGSTOWN STATE UNIVERSITY Date of Care: 10/4/2022

Department of Nursing Nurse’s Name: Connie

Nursing 4840L Clinical Data Base

Student: Feng Chen

Pt’s Initials: J.D Date admitted: 9/19/2022 Height: 5 ft 10 in
Room #: 3807 DNR status: Full Adm. Weight: 184lb
Age: 70 Isolation type: None
Sex: Male Allergies: NKA

Diagnosis (es): Subdural hematoma, subarachnoid hemorrhage

Reason for Admission/Events Leading to Current Hospitalization:

(Include reason patient is still in Unit > 2 days if appropriate)
Patient fell down the steps at home. Patient arrived at the ED as a trauma alert on 9/19. CT scan
showed subdural hematoma, subarachnoid hemorrhage, orbital bone fracture and sphenoid bone
fracture. On the same day, patient admitted to the SICU. On 9/26 patient was intubated due to
worsening respiratory status. Bronchoscopy was done to clear secretions through ETT. Patient require
long-term mechanical ventilation. On 10/4 Patient received a tracheostomy and PEG tube

Pertinent History of Illnesses/Surgery:

Not on file

Oxygenation: tracheostomy Vent Settings: Pain:

Trach (size/type): Shiley style/ Mode: A/C Score: 0
8mm Rate: 14 Scale Used: CPOT
FiO2: .90 Location: N/A
TV: 450 Duration: N/A
PEEP: 10 Intervention: N/A
PSV: None Re-eval (30 min): 0

Intake/Output/Weight:
24 hr. Intake: 448.8 Today’s Weight: 215.38 Prior Day’s Weight: Not measured
24 hr Output: 952 Cumulative Fluid Balance: -503.2

Revised 8/20 lrcalcagni & cmshields Page 1

Head to Toe Assessments

Neurological:
LOC: Response to voice & Orientation: UTA, intubated Ordered Sedation: Propofol
stimulus
Opens Eyes: To speech & touch GCS: 8 Pupils: 4mm, round, reactive bilaterally

Speech: UTA, intubated Tongue: Coated Face Symmetry: Symmetrical

Cardiovascular:
Rhythm: NSR Pulse: Regular/Irregular Heart Sounds: noraml S1 & S2
JVD: None Cap Refill: (<3 sec) (>3 sec) CVP: N/A PCWP: N/A
Cyanosis Location: None Pacemaker: None

Peripheral Vascular:
Pulses: (Palp or Doppler) Radial: R +2 L +2 Pedal: R +1 L +1 Post Tibial: R +1 L +1
Edema: Yes/No Location: Generalized Degree: +3 pitting

Respiratory:
Breath Sounds: Ronchi in all fields Cough: No (Productive/Nonproductive)
Chest Tubes (Location/system/Sx setting): None
Sputum: Copious amount, red, tan, thick

GI:
Diet: NPO TPN: N/A TF (type/rate): Glucerna; 45ml/hr
NG/OG/PEG/FT (circle) NG Sx Drainage: N/A Abdomen: Soft, round
Bowel Sounds: Active x 4 Stool: Y / N Incontinent: Y / N
Ostomy (type): N/A FMS: Yes Color/charac: brown, loose

GU:
Urine: Yellow Clarity: Clear Amount: 445mL Catheter Type/size: External
Genital Irritation: Y / N Dialysis (type/site): N/A catherter

Skin:
Temp: Warm, cool on the legs Color: Pink, pale Turgor: Good
Mucous membranes: Dry Incisions: Treachostomy & PEG
Wounds: Abrasions on the nose

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Musculoskeletal:
UE Movement: Limited Strength: UTA Sensation: UTA

LE Movement: Limited Strength: UTA Sensation: UTA

Continuous IV Drips: IV Drips must also be looked up & included on Med Sheet

Medication Concentration Rate Site Line

0.9 % NaCl N/A 240 mL/hr Right brachial PICC

Cefepime 2000mg in 50 mL NSS 100 mL/hr Right brachial PICC

ABG Analysis:
ABG’s: pH PCO2 PO2 HCO3 Interpretation
Admission 7.361 34.8 114.1 19.3 Compensated metabolic acidosis
Date:
Day prior 7.510 33.4 95.4 26.1 Uncompensated respiratory alkalosis
Date:
Day of care 7.468 38.2 79.3 27.1 Uncompensated metabolic alkalosis
Date:

Diagnostic Test: Results:

Chest X-Ray 10/4: multiple infiltrate worse in the right upper lobe are unchanged. Heart size
(include date) is normal. There are no effusion. Support lines are appropriate

Other pertinent Head CT (9/18): right & left subarachnoid hemorrhage. Small right subdural
diagnostic tests
hematoma. No significant midline shift. Multiple fracture of the head
(include date)
Head CT (9/19): NO significant changes

Head CT (9/24): continued reabsorption & resolution of blood products

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Pathophysiology of Primary Diagnosis or Surgery (include book used & page #)
Subdural hematoma: a collection of blood between the dura & the brain, a space normally occupied by
a thin layer of cushion (Hinkle & Cheever, 2018, pg.2037)
Subarachnoid hemorrhage: hemorrhage into the subarachnoid space (Hinkle & Cheever, 2018, p.g
2026)

Reference:
Hinkle, J.L & Cheever, K.H. (2018). Brunner & suddarth’s textbook of medical-surgical nursing.
Wolters Kluwer

Psychosocial Considerations:
Patient had tracheostomy & PEG tube done today. Patient is going to a long-term facility, and patient
has a pending divorce with his wife. A lot of negative changes in patient’s life, and patient might need
help to cope with them all at once.

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 Normal Admission Day prior Day of care
Lab Test Values 9/18/2022 10/3/2022 Reason for Abnormal Value
Date
10/4/2022
Na+ 132-146 141 140 140 N/A
K+ 3.5-5.0 3.9 4.0 3.6 N/A
Cl- 98-107 101 105 105 N/A
CO2 23
BMP

22-29 24 25 N/A
Glucose 74-99 343 212 144 Stress
BUN 6-23 10 18 20 N/A
Creatinine 0.5-1.0 0.9 0.7 0.7 N/A
Calcium * 8.2-10.2 9.5 8.3 8.6 N/A
Albumin 3.5-5.2 3.9 0.9 0.8 Malnutrition
CMP (+ BMP)

Total protein 6.4-8.3 7.3 5.8 5.6 Malnutrition

ALP (Alk Phos) 35-104 123 543 483 Fracture bone
ALT/SGPT 0-32 11 28 23 N/A
AST/SGOT 0-31 20 48 29 N/A
Total Bilirubin 0.0-1.2 <0.2 0.7 0.3 N/A
Magnesium 1.6-2.6 Not draw 2.0 2.2 N/A
El

Phosphate 2.5-4.5 Not draw 3.7 3.4 N/A

Cholesterol 140-400 Not draw Not draw Not draw N/A
Lipid

Triglycerides <150 Not draw Not draw Not draw N/A

RBC 3.50-5.50 4.44 2.65 2.51 Brian hemorrhage, iron deficiency
Hgb 11.5-15.5 13 7.7 7.3 Brian hemorrhage, iron deficiency
Hct 34.0-48.0 40 24 22.8 Brian hemorrhage, iron deficiency
Platelets 130-450 339 188 224 N/A
CBC

WBC 4.5-11.5 14.4 18.5 17 Infection, inflammation

neutrophils 43.0-80.0 71.3 88.7 88.3 Infection, inflammation
lymphocytes 20.0-42.0 17 3.5 2.7 Malnutrition
monocytes 2.0-12.0 7.4 1.7 4.5 N/A
eosinophils 0.6-6.0 2.2 0.9 1.8 N/A
basophils 0.0-2.0 0.9 0.9 0.5 N/A
PT 9.3-12.4 Not draw Not draw Not draw N/A
Coag

INR 1-1.5 Not draw Not draw Not draw N/A

HPTT/PTT 18-28 Not draw Not draw Not draw N/A
CK 38-174 Not draw Not draw Not draw N/A
Cardiac

CK MB 0-3 Not draw Not draw Not draw N/A

Troponin <0.4 Not draw Not draw Not draw N/A
B-type natriuretic
peptide (BNP)
<100 Not draw Not draw Not draw N/A
Lactate <2 Not draw Not draw Not draw N/A
Ammonia 15-45 Not draw Not draw Not draw N/A
Other

GFR >60 >60 >60 >60 N/A

* Calcium part of BMP in some facilities

otherwise in CMP

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

1. Rate: 84 2. R-R Interval Regular: Y / N

3. P wave present: Y / N 4. PR Interval: 0.06 Constant: Y / N
5. P precedes each QRS: Y / N 6. QRS Interval: 0.08
7. QT Interval: 0.40 8. ECG Interpretation: NSR with PAC

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Medications (Include all scheduled meds & continuous IV meds, even if student is not administering on shift)
Allergies: ________________________________________________________________________
Generic Name Dose Route/How Reason Pt. Receiving 2 Common Side Effects
----------------------------- to
Classification administer
Acetaminophen 650mg PEG tube Treat mild pain 1. Acute liver failure
2. Nausea & vomiting
Analgesic

Acetylcysteine 4mL Inhalation Breakdown the 1. Increase coughing

secretion in the lungs; 2. Fever
Mucolytic antidote for
Acetaminophen
Amiodarone 200mg PEG tube Treat cardiac 1. Lightheadedness
dysrhythmia 2. Numbness or
Anti-arrhythmia tingling in finger or
toes
Cefepime 200mg IV Treat bacterial 1. Abdominal cramps
infection 2. Bleeding gums
Antibiotic

Duloxetine 30mg PEG tube Treat depression, 1. Blurred vision

anxiety, or nerve pain 2. Dry mouth
Anti-depressant

Fentanyl 100mg IV Treat severe pain 1. Respiratory

(pain level 7-10) depression
Narcotics 2. Sedation
Heparin 50000U SubQ Prevent blood clot 1. Bleeding
2. Bruising
Anticoagulant

Hydralazine 10mg IV Treat HTN 1. Hypotension

SBP >140 & HR <75 2. Headaches
Vasodilator

Propofol 418.5 to IV Sedation 1. Slow, irregular HR

4185mcg/min 2. Impaired mobility
Anesthetic

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 #1
Key Problem/ND
1 #3
Impaired gas exchange
#2 Key Problem/ND 1
Key Problem/ND 1 Supporting data: Impaired skin
Ineffective airway Tracheostomy integrity/risk for infection
clearance Vent mode: A/C
FiO2 .9 Supporting data:
Supporting data: vT 450 Abrasions and ecchymosis
Rhonchi in all lung fields PEEP 10 on the face, arms and legs
Copious amount of GCS 8 Tracheostomy & PEG site
secretion, thick, red, tan Cefepime 2000mg Q8H IV
Bronchoscopy to remove infusion
secretion Elevated WBC 17.0
Frequent suctioning via Elevated neutrophil 88.3%
tracheostomy
Acetylcysteine 4mL BID Reason for Needing Health
Care (Medical
Diagnosis/Surgical
Procedure)
Subdural hematoma
Subarachnoid hemorrhage
Multiple fractures of the head
Tracheostomy & PEG

Key assessments:
VS with focus on neuro &
respiratory
#5
Allergies: NKA
Key Problem/ND 1 #6
Ineffective tissue perfusion Key Problem/ND 1
Impaired verbal
Supporting data: communication
Low RBC 2.51
Low Hgb 7.3 Supporting data:
#4 Intubated with tracheostomy
Low Hit 22.8 Key Problem/ND 1
Pink pale skin GCS 8
Imbalanced nutrition: less
Cool skin temperature on lower Eye opening to speech and
than body requirement
extremities touch
Post tibial pulse +1 bilaterally Propofol IV
Supporting data:
Pedal pulse +1 bilaterally NPO
Immobility Glucerna 45mL/hr per PEG
Low albumin 0.8
Low total protein 5.6
Low lymphocyte 2.7%
Anemic/iron deficiency
Low RBC 2.51
Low Hgb 7.3
Low Hct 22.8

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 Problem #1: Impaired gas exchange
General Goal: Increased gas exchange
Predicted Behavioral Outcome Objective(s): Patient will maintain a SPO2 level >95% on .9 FiO2,
ABGs WNL, and show no signs of cyanosis on the day of care

Nursing Strategies Patient Response

1. Auscultate breath sounds 1. Rhonchi in all lung fields
2. Monitor respiratory pattern for 2. Respiration unlabored, regular depth,
rate, depth & effort hyperventilating (rate 21-24)
3. Assess SPO2 QH 3. SPO2 maintain at 98% on .9 FiO2
4. Assess tracheostomy tube 4. No leakage, kink, or disconnection
5. Check ABGs 5. Uncompensated metabolic alkalosis; PaO2 79.3
6. Check daily chest x-ray result 6. Tube placement appropriate; infiltration in the
7. Elevate HOB 30 degrees right lobe
8. Assess for cyanosis 7. HOB elevated to 30 degrees; pt tolerate well; no
9. Check vent settings per shift signs of VAP
8. Skin pink and pale
9. Pt on A/C mode, FiO2 .9, vT 450 & PEEP 10
Evaluation: Patient maintain SPO2 >95% on .9 FiO2; his ABG result shows uncompensated
metabolic alkalosis, and there is no sign of cyanosis on the day of care

Problem #2: Ineffective airway clearance

General Goal: Maintain airway patency
Predicted Behavioral Outcome Objective(s): Patient will have clear breath sounds bilaterally with
thinner and decrease amount of mucus on the day of care

Nursing Strategies Patient Response

1. Hyper-oxygenate & suction PRN 1. Patient require frequent suctioning; pt tolerated
2. Auscultate bilateral breath sounds well
3. Monitor respiratory pattern for 2. Breath sounds are clear bilaterally after
rate, depth & effort suctioning
4. Assess mucus for amount, color, 3. Respiration unlabored, regular depth,
and consistency hyperventilating (rate 21-24)
5. Check suction system 4. Mucus is copious, tan, red, and thick
6. Prepare patient for bronchoscopy 5. Suction system is functioning properly
if ordered 6. Patient does require bronchoscopy on the day of
7. Administer acetylcysteine per care
order 7. Acetylcysteine was administered by RT
8. Reposition Q2H 8. Patient repositioned Q2H; pt tolerated well
Evaluation: Patient maintain SPO2 >95% on .9 FiO2; his ABG result shows uncompensated
metabolic alkalosis, and there is no sign of cyanosis on the day of care

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 Problem #3: Impaired skin integrity/ risk for infection
General Goal: No skin breakdown & no signs of infection
Predicted Behavioral Outcome Objective(s): Patient’s skin will be clean, dry, intact, show no signs
of breakdown and infection on the day of care

Nursing Strategies Patient Response

1. Reposition Q2H
2. Dressing change per shift or PRN
3. Assess skin per shift
4. Perform skin care per shift or
PRN
5. Administer Cefepime as ordered
6. Perform universal precaution &
strict handwashing
Evaluation: Patient show no signs of skin breakdown. Patient’s WBC & neutrophil levels are elevated
on the day of care
1. Patient repositioned Q2H; patient tolerated well
2. Patient’s ACE wrap changed
3. Patient have abrasions & ecchymosis on face,
arms & legs. Surgical incision at tracheostomy &
PEG site
4. Patient is cleaned with bath wipes, gown & linen
changed, bed pads changed.
5. Cefepime infused at 100mL/hr; pt tolerated well
6. Universal precaution & strict handwashing are
followed

Problem #4: Imbalance nutrition: less than body requirement

General Goal: Weigh within normal range for height and age
Predicted Behavioral Outcome Objective(s): Patient’s lab value will show an improvement in
nutritional status, as indicated by increased albumin and total protein levels and electrolytes WNLs
on the day of care

Nursing Strategies Patient Response

1. Continuous tube feed 1. Glucerna 45mL/hr; patient tolerated well
2. Check PEG tube site per shift 2. PEG tube is functioning properly; no clot, kink or
3. Draw & check labs per shift disconnection. Site is clean & dry
4. Assess GI system per shift 3. Albumin 0.8, total protein 5.6, glucose 144
5. Monitor stool for color & 4. Bowel sounds normoactive x4; abdomen round &
consistency soft
5. Stool is brown & loose; patient has an FMS
Evaluation: Patient’s lab values still shows malnutrition, with albumin of 0.8, total protein of 5.6, and
electrolytes are WNLs on the day of care

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 Problem #5: Ineffective tissue perfusion
General Goal: Increase tissue perfusion
Predicted Behavioral Outcome Objective(s): Patient will demonstrate adequate tissue perfusion as
evidence by palpable peripheral pulses, warm & dry skin, MAP >65mmHg and BP WNL on the day
of care
Nursing Strategies Patient Response
1. Assess peripheral pulses 1. Radial pulses +2 bilaterally; post tibial & pedal
2. Assess skin temperature pulse +1 bilaterally
3. Assess capillary refill 2. Skin is warm on upper extremities & cool on
4. Assess for edema lower extremities
5. Monitor MAP 3. Capillary refill <3 seconds
6. Monitor vital signs 4. Generalized +3 pitting edema; feet elevated
7. Administer 0.9% NaCl as ordered 5. MAP >65mmHg
6. BP 109/61, HR 89, temp 98.9, SPO2 98
7. 0.9 NaCl infuse at 240mL/hr continuously
Evaluation: On the day of care, patient’s pulses on upper extremities are +2 & +1 for lower
extremities. Patient’s skin is warm on upper extremities & cool on the lower extremities. Patient
maintain MAP >65mmHg (range from 73-77). Patient’s BP remain low (range from 99/68 – 110/58)

Problem #6: Impaired verbal communication

General Goal: Use alternative method of communication effectively
Predicted Behavioral Outcome Objective(s): Patient will be more alert, as evidence by improved
GCS score (>8)
Nursing Strategies Patient Response
1. Neuro assessment per shift 1. Patient opens eyes to speech, withdrawal from
2. Use appropriate pain scale pain, pupils 4mm reactive bilaterally & GCS 8
3. Perform sedation vocation 2. CPOT scale was used; patient scored 0/8
4. Explain all healthcare procedure 3. Patient off sedation but is obtunded
to the patient 4. All procedures are explained; patient unable to
5. Observe for nonverbal cues demonstrate understanding
5. Patient show no purpose movements
Evaluation: On the day of care, patient show little signs of alertness. Patient is unable to follow
command or have any purposeful movements. Patient’s GCS remains at 8.

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