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CSU, STANISLAUS B.S.N.
CLINICAL PLAN OF CARE
Student:
Sara Hannah
Date of Care:
1/13-1/14
Room Number:
3509
Patient Data
Admitting Diagnosis
Atrial fibrillation with RVR, SIRS r/o sepsis
2/2 UTI, ESRD with missed dialysis
Age
68
Spiritual Focus
unknown
Culture
Caucasian, not hispanic
Patient Initials
P.G.
Gender
Female
Height
63 inches
Weight
83.7 kg
Admitting Date
1/6/15
Vital Signs
T
Admission: 36.8
1/13: 37.1
1/14:
P
R
B/P
O2Sat
154
20
110/96
98% RA
145
18
102/68
96% 2 L NC
Pain Scale
Unable to obtain r/t
AMS
0/10
Past Medical History
Hypertension, hyperlipidemia, COPD, osteoarthritis, chronic back pain, L kidney atrophy, R renal artery stenosis, ESRD, hemodialysis, systolic CHF
2/2 severe aortic stenosis, psych disorder
Surgical History
Tubal ligation, renal angiogram with thrombus and stenosis or R renal artery, thrombolysis, thromboplasty with stent of R renal artery
Diet:
Foley:
Cardiac
prudent/renal diet
None; anuric
Activity:
bed bound, in soft restraints, vest
NG/Feeding Tube:
none
Drains/ Tubes:
none
Advance Directives:
Yes
Code Status:
Full
VS Freq:
Q4H
TEDs/SCDs:
SCDs in place
PCA/Epidural:
None
Telemetry:
Yes
R FA, TDC R subclavian
Glucose
Monitoring:
Not since initial labs
Vascular Access:
IV Site:
IV Solution:
Safety Considerations:
Fall precautions,
Dressing Changes:
Dressing change to stage I decubitus ulceration to sacral area
Labs Drawn:
CBC, CMP, lipase, BNP, PT, INR, Troponin, BC x1, BC x2, UA, urine micro, urine C&S, ABGs, lactate
Scheduled Procedures:
Done: CXR, echocardiogram, EKG
Notes on Pathophysiology:
Atrial Fibrillation with RVR: Atrial fibrillation is the most common type of arrhythmia. Approximately four percent of
the U.S. population has either intermittent or permanent Afib. In people over the age of 60, the incidence rises to
about nine percent. AFib is caused by abnormal electrical impulses in the atria. The result is a rapid and irregular
pumping of blood through the atria. These chambers fibrillate, or quiver, rapidly. AFib may or may not produce
symptoms or cause serious complications. In some cases of AFib, the fibrillation of the atria causes the ventricles to
beat too fast. This is called a rapid ventricular rate or response (RVR). If you have AFib with RVR you will experience
symptoms, typically a rapid or fluttering heartbeat. RVR can be detected and confirmed by your doctor. It can cause
serious complications and requires treatment.
SIRS/ VRE: An inflammatory state affecting the whole body, frequently a response of the immune system to infection,
but not necessarily so. It is related to sepsis, a condition in which individuals meet criteria for SIRS and have a known
infection. It is the body's response to an infectious or noninfectious insult. Although the definition of SIRS refers to it
as an "inflammatory" response, it actually has pro- and anti-inflammatory components. Vancomycin-resistant
enterococci (VRE) are a type of bacteria called enterococci that have developed resistance to many antibiotics,
especially vancomycin. Enterococci bacteria live in our intestines and on our skin, usually without causing problems.
But if they become resistant to antibiotics, they can cause serious infections, especially in people who are ill or weak.
These infections can occur anywhere in the body. Some common sites include the intestines, the urinary tract, and
wounds. Vancomycin-resistant enterococci infections are treated with antibiotics, which are the types of medicines
normally used to kill bacteria. VRE infections are more difficult to treat than other infections with enterococci,
because fewer antibiotics can kill the bacteria.
Transaminitis: A regionally popular term for increased transaminases (AST, ALT) coupled with non-specific hepatitis,
which may occur in a patient undergoing the early stages of multiorgan failure.
Scheduled: CT scan on 1/15
Lab and Diagnostic Test Data
Test type
(date)
Chem-7
Na
Normal
Range
Pt Results
High/Low
135-145
129
low
K
Cl
CO 2
3.3-5.0
95-110
24-32
4.8
98
20
nl
nl
low
Glucose
Calcium
Phosphorus
Magnesium
Kidneys
BUN
70-110
8.6-10.2
3.0-4.5
1.2-2.0
97
nl
8-22
51
high
Creatinine
0.5-1.3
4.9
HIGH
GFR
>60
Rationale
(specific to pt)
Nursing implications related to patient
care & teaching
Could be due to poor nutrition. In care
facility PTA, the patient was refusing
meals and medications. Could also be
related to chronic renal insufficiencies
that do not spare Na. Also can be
diminished by diuretics.
-Monitor IV fluid intake so it is not
providing less sodium than maintenance
and ongoing losses
-Make sure the patient does not only
appear hyponatremic due to increase in IV
fluids acting as dilutant
Occurs in renal failure. Patient is in
end stage renal failure.
-Drugs that may cause decreased levels
include methicillin, nitrofurantoin,
paraldehyde, phenformin, tetracycline,
thiazide diuretics and triamterene
-Related tests: ABGs
ESRD causes diminished renal blood
flow causing decreased renal
excretion of BUN. Sepsis also could be
a cause which decreases renal blood
flow as well.
Directly proportional to renal
excretory function. Extensive renal
impairment history; on dialysis
-Is a measurement of renal function, GFR
and liver function
-Monitor for nephrotoxicity caused by
drugs such as potassium or aspirin
-Consider BUN/Creatinine ratio
-Similar to BUN test but levels tend to rise
later
-Suggests chronicity of the disease process
-Interpreted in conjunction with BUN
-The patient’s value is extremely elevated
Test type
(date)
Liver
Total Protein
Albumin
Normal
Range
Bilirubin Total
Alk phos
AST
ALT
Cardiac
CPK
CPK-MB
0.3-1.3
20-180
8-42
10-60
Troponin
Myoglobin
<3.1
0-85
Blood
WBC
4.5-11.0
3.8-5.1
0-250
<7.5
Pt Results
High/Low
Rationale
(specific to pt)
Nursing implications related to patient
care & teaching
2.7
low
Can be caused by malnutrition (low
protein levels). Most likely the liver
disfunction (albumin synthesis)
associated with malnutrition also
contributes to low level.
-Measurement of hepatic function
-Maintains colloidal osmotic pressure
-Helps transfer drugs, hormones, enzymes
-Factor in that with low albumin, drugs
administered may not be getting to full
efficacy
7.8
high
Suggests myocardial muscle injury
specifically to myocardial cells. Can
occur in patients with unstable angina
such as this patient and will signify an
increased risk for an occlusive event
-Used in timing of onset of infarct in
patients with MI.
-Rises 3-6 hours after infarction, peaks 1224 hours, and then returns to normal 1248 hours.
-Used to appropriate thrombolytic
therapy
-Signifies increased risk of thrombolytic
events
18.0
high
Signifies infection or inflammation or
tissue necrosis or stress on the body
especially related to VRE UTI diagnosis
-Administer daily antibiotics as ordered
-Monitor visitors and initiate appropriate
ppd precautions
-Monitor vitals, especially temperature
Q1H
Test type
(date)
Hgb
Normal
Range
13-16
9.4
low
Hct
RBC
37-49
4.5-5.3
28.1
2.73
low
low
Platelets
INR
PT
PTT
aPTT
Blood Gas
PaO 2
Sa O 2
Ph
PaCO 2
HCO3
URINALYSIS
Color
130-400
151
nl
3+
high
Clarity
Spec. Grav.
Occ. Blood
Pt Results
High/Low
Rationale
(specific to pt)
Could be caused by expanded blood
volume related to IV fluid delivery.
Nursing implications related to patient
care & teaching
-Rapid indirect measurement of RBCs
-Monitor kidney function since
erythropoietin is a strong stimulant to RBC
production and is made in the kidneys
See above
See above
Erythropoietin is made in the kidney
-Women tend to have lower levels than
and is a strong stimulant of RBCs. With men
reduced levels of erythropoietin being -RBC counts tend to decrease with age
produces with kidney failure, RBC
-When lower than normal values, patient
levels drop
is said to be anemic
80-100
90-100
7.35-7.45
35-45
22-28
Pale
yellow
Clear
1.0021.030
0
Any disruption in the blood-urine
barrier (at the glomerular, tubular or
bladder level with cause RBCs to enter
the urine
-Traumatic catheterization or over
aggressive anticoagulation can cause
hematuria
-mutiple possible causes including UTI,
primary renal disease, renal stones, etc.
Test type
(date)
Ketones
Glucose
Proteins
Normal
Range
0
0
0
3+
high
Injury and dysfunction to glomerulus
of the kidneys as in kidney failure,
kidney atrophy
-The combination of proteinuria and
edema is called nephrotic syndrome
-Protein is a sensitive indicator of kidney
fxn
-Usually albumin (smallest)
PH
WBC/HPF
4.8-7.8
0-2
TNTC
high
Indicated UTI involving the bladder, or
kidneys, or both
-A clean catch urine should be done for
further evaluation
-Referred to as leukouria
RBC/HPF
0-2
Bacteria/casts 0
Moderate/9-25
high
Patient’s culture showed Vancomycinresistant enterococci; UTI
X-RAY
CXR
No infiltrates
nl
CT SCAN
EKG
1/6
Atrial flutter with
ventricular
response of 154.
Normal axis,
nonspecific ST
changes, no
other ectopy
Performed over concern for
pneumonia or UTI related to crackles
in lungs, reported dysuria and bands
on CBC
Scheduled for 1/15
New onset
-Casts are conglomerations of
degenerated cells
-WBC casts are most frequently found in
infections of the kidney such as acute
pyelonephritis or interstitial nephritis
CXR was negative; most likely cause for
bands on CBC will be infection in urine
US
OTHER
Pt Results
High/Low
Rationale
(specific to pt)
Nursing implications related to patient
care & teaching
-Place on telemetry
-Ongoing monitoring of vital signs
-Start anticoagulants
-Medication reconciliation important
Medication Allergies:
NKDA
Medications
Generic & Trade Name
Drug Classification
Dose/Route
Frequency
(Therapeutic &Pharmacologic)
Simvastatin
Zocor
Antihyperlipidemic
20 mg/ 1 tab PO
QD at bedtime
Carvedilol
Coreg
Alpha/Beta-Adrenergic
blocker, antihypertensive
cardiovascular agent
25 mg/ 1 tab PO
Q12H
Action of drug and
Rationale
(specific to Pt)
Lipid lowering agent that
is readily hydrolyzed to
the corresponding betahydroxyacid. Increases
the rate of removal of
cholesterol from the
body and reduces its
production by arresting
the conversion of HMGCoA, which is a rate
limiting step in the
biosynthesis of
cholesterol. Given to pt
for hx hyperlipidemia.
Nonselective betaadrenergic blocking
agent that has
antihypertensive effect
by causing vasodilation
reducing peripheral
vascular resistance.
Decreases cardiac
output, decreases
tachycardia. Given to this
patient r/t Hx HTN and
CHF
Significant Side Effects
Nursing implications related to
patient care & teaching
May cause constipation,
nausea, abdominal pain,
headaches, insomnia,
vertigo and upper
respiratory infections. Other
side effects include
abdominal pain, nausea,
headache, jaundice,
cholestatic hepatitis,
increased liver enzymes,
liver failure, compartment
syndrome of the lower leg,
muscle disorder
-Counsel patient to immediately
report s/s of myopathy or
rhabdomyolysis including muscle
pain, tenderness and/or weakness
-Instruct patient to report s/s of liver
injury such as fatigue, anorexia, right
upper abdominal discomfort, dark
urine or jaundice
-Instruct patient to avoid grapefruit
juice while taking this drug
-Multiple drug interactions
May cause diarrhea, nausea,
vomiting, arthralgia, back
pain, myalgia, headache,
vision disorder, erectile
dysfunction, reduced libido,
fatigue.
-Hold for sbp <110 or hr <60
-Instruct patient to report s/s of
adverse cardiovascular effects such
as hypotension (especially in the
elderly), arrhythmias, syncope,
palpitations, angina, edema
-Drug may mask symptoms of
hypoglycemia. Advise diabetic
patients to carefully monitor blood
sugar levels
-Should take with food
Sevelamer HCl
Renagel
Bile acid sequestrant/
Phosphate binder
800 mg/ 1 tab PO
Benztropine
Cogentin
Anticholinergic/
Antiparkinsonian
1 mg / 1 tab PO
BID
Haldol
Haloperidol
Antipsychotic/ Dopamine
antagonist
2.5 mg IV Q8H
PRN for agitation
Phosphate binder that
inhibits intestinal
phosphate absorption
and reduces LDL and
total serum cholesterol
levels. Given to this
patient to avoid
hyperphosphatemia that
is caused by ESRD and
hemodialysis
Similar structural
features found in
atropine and
diphenhydramine. The
anticholinergic activity is
utilized in the treatment
of parkinsonism. In the
case of this patient, it is
given as an adjunct
psych medication to
avoid agitation; sedative
effects
Patient did not need this
PRN for agitation on
1/13 or 1/14. Patient
appeared calm after
administration of
benztropine.
May cause abdominal pain,
constipation, diarrhea,
flatulence, indigestion,
nausea, vomiting, bowel
obstruction, perforation of
intestine, peritonitis
-Restricted to dialysis patients only
-May cause hypotension, dyspepsia,
nausea, vomiting
-Advise patient to report s/s of
thrombotic disorder
-Patient should take drug with meals
and adhere to prescribed diet
May cause anticholinergic
effects, tachyarrhythmia,
paralytic ileus, confusion or
drug-induced psychosis
-May impair heat regulation
-Instruct patient to report sudden
muscle weakness or stiffness and s/s
or tardive dyskinesia.
-Patient should not consume ETOH
while taking this drug
May cause hypotension,
constipation, xerostomia,
akathisia, dystonia, EPS,
somnolence, blurred vision,
prolonged QT inverval,
Torsades de pointes, nasal
congestion, obstipation
-May impair heat regulation
-May cause anticholinergic effects
-Instruct patient to report EPS,
tardice dyskinesia or neuroleptic
malignant syndrome
1.) Diagnosis: Risk for deep vein thrombosis related
to venous stasis associated with decreased mobility
and increased blood viscosity if fluid intake is
inadequate as evidenced by:
2.) Diagnosis: Decreased cardiac output
related to history of CHF and new onset atrial
fibrillation/atrial flutter as evidenced by:
Data to Support:
-Increased time spent supine, no physical activity
-Hx MI
-in soft restraints and wears vest
-Does not make urine so no need to ambulate to
bathroom
Data to Support:
-New onset atrial fibrillation/flutter
-ECG changes
-Elevated CPK-MB
-Poor capillary refill
-Hx CHF with severe aortic stenosis
-Fatigue, edema
Interventions:
• Reposition client avoiding positions that
compromise blood flow
• elevate foot of bed for 20-minute intervals several
times a shift
• SCDs
• maintain a minimum fluid intake of 2500
ml/day unless contraindicated to prevent
increased blood viscosity
• administer anticoagulants (e.g. low- or adjusteddose heparin, warfarin, low-molecularweight heparin) if ordered
Expected Outcome/Goals:
-Patient’s pulse rate remains within set limits
-Skin will remain warm and dry
-Patient will be compliant with newly
prescribed cardiac medications and Lasix
medication
-Patient will exhibit no pedal edema
-Patient will maintain adequate cardiac output
-Patient will verbalize understanding of
reportable signs and symptoms
-Patient will verbalize understanding of diet,
medication regimen, prescribed activity level
Expected Outcome/Goals:
The client will not develop a deep vein thrombus as
evidenced by:
• absence of pain, tenderness, swelling, and
distended superficial vessels in extremities
• usual temperature of extremities
• negative Homans' sign.
Admitting Diagnoses: SIRS rule out Sepsis, Atrial
Flutter, Acute Transaminitis, ESRD (on hemodialysis),
Systolic CHF 2/2 Severe Aortic Stenosis
Discharge Diagnoses: New Onset Atrial Fbrillation,
Sepsis 2/2VRE UTI, Acute Delirium 2/2 Sepsis
3.) Diagnosis: Risk for ineffective
cerebral tissue perfusion related to
atrial fibrillation and possible
thrombus formation as evidenced by:
Data to Support:
-New onset atrial fibrillation
-Unstable cardiovascular status
-ALOC/LOC
-Weakness
-Disorientation
Expected Outcome/Goals:
-Patient will understand the need for
frequent assessments to assess for
any changes in neurological status
-Patient will experience adequate
cerebral perfusion evidenced by
normal neurologic checks
-Pt will remain hemodynamically
stable
-Patient will participate in diagnostic
testing when necessary
-Patient will verbalize strategies to
minimize or decrease modifiable risk
factors
-Patient will not develop facial droop
or hemiplegia
-Patient will report any abnormal
sensations
5.) Diagnosis: Risk for impaired skin integrity related to stage I community acquired decubitus ulceration as evidenced by:
Data to Support:
-Two areas of erythema to sacral and coccyx regions
-Patient is non-ambulatory and is fall risk
-Patient is in restraints
-Patient does not make urine; does not get up to void
-Patient receiving Haldol which causes the patient to sleep in the same position for long amounts of time
Expected Outcome/Goals:
-Patient will maintain intact skin -Patient will describe normal aging changes in skin and risk factors for disturbance in skin integrity
-Patient or caregiver will implement strategies to prevent skin breakdown and will carry out skin care regimen -No further skin breakdown
Student Clinical Self-Appraisal
Weekly (turn in with Care Plan/Map)
Student : Sara Hannah
Course: Nurs 4810
Instructor: Mia Alcala-Van Houten
Instructions: Please evaluate your performance during clinical today using the following concepts:
Patient Advocate
Professional Demeanor
Flexible
Critical Thinking
Communication/rapport
Peer Support
Self-Initiated
Team Player
Skill Acquisition
Safety
Organized
Educator
Leadership
Well-prepared
Dependable
Nursing Process
Knowledgeable
Areas of Strength Today (Date)
Organized: finally able to decipher through the charts
and be efficient at recording information
Critical Thinking: Given autonomy by my nurse and felt
confident with the tasks given
Instructor Comments:
Areas Needing Growth-Include plan of
improvement
Safety: I need to review insulin precautions and
what type is which
Well prepared: My nurse needed a pen light and I
had left mine in my bag. I hate when things like that
happen and I cant be of help
NURS 4810
Plan of Care Evaluation
Student Name: Sara Hannah
Date:
Week#:
Faculty:
Instructions: Attach a copy of this form to each of you Clinical Plan of Care/Maps for grading purposes.
1. Patient Data includes: (10 pts.)
_________/10
a.
Physical data
b.
Health history
c.
Interventions as ordered
2. Each medication includes (10 pts.)
_________/10
a.
Name (Trade & Generic)
b.
Rationale
c.
Side effects
d.
Nursing Implications
3. Laboratory Data (10 pts.)
_________/10
a.
Patient Values and Trends
b.
Etiology & Implications for the patient
4. Concept Map includes all appropriate physiologic, psychologic or social problems, discharge planning & pt.
education (20pts):
_________/20
5.
Each problem includes (20 pts):
a. Nursing diagnosis
b. Data to support
c. Appropriate interventions
6. Critical Assessments are appropriate to diagnosis (10pts)
7. Evaluation of Interventions includes (10 pts):
a. Physical interventions
b. Psychosocial interventions
c. Patient education
8. Appearance of Overall Care Map (10 pts)
Total:
Comments:
_________/20
_________/10
_________/10
_________/10
__________%