FLORIDA INTERNATIONAL UNIVERSITY
Nicole Wertheim College of Nursing and Health Sciences
CLINICAL WORKSHEET: NURSING PROCESS CARE PLAN
STUDENT NAME
DATE
Unit: Medical/Surgical
Religion: Catholic
Support system: Wife and son
Room/Bed: 206-Window
Age:62
Sex: Masculine
Language: Spanish
Weight:68 kg Height:165cm BMI: 24.98
Marital status: Married
Current medical diagnosis: Dyspnea
Occupation: Contractor
Siblings: None
Sinus tachycardia,
Health insurance: Humana Medicare
Name of significant other/primary caregiver:
Primary Care Doctor: Rolando Diaz MD
COPD exacerbation
Current work status: Employed
Pulmonary Emboli
Highest grade completed: High School
Atypical Chest Pain
Alcohol: Socially
Non-Smoker
Denies Drug Use
Sexually active
Chronic Anticoagulation
Genogram: Use back of page
Wagner Syndrome
Diagnostic Data (include date(s) and results()):
Chest CT-Scan showed bilateral pulmonary emboli (01/27/2024)
Surgical procedures (current and past with date(s)):
No past surgical history
Past Health History: Hypertension, Pulmonary Emboli, Diabetes, Upper airway stricture
1
History of Present Illness: Present is a 62-year-old male with a past medical history of Hypertension, COPD, Pulmonary Embolism, Upper
Airway Stricture and Diabetes. Patient presented with a chief complaint of Shortness of breath and chest pain with increasing breathing difficulties.
Patient admitted to Unit for treatment of Pulmonary Emboli and COPD exacerbation (01/28/24).
Review of Systems
HEENT: No headaches, head injuries, or lumps. No vision changes, eye pain, or discharge. No hearing loss, earaches, or tinnitus. No nasal
congestion, discharge, or nosebleeds. No sore throat, difficulty swallowing, or voice changes
NEURO: No headaches, seizures, numbness/weakness, coordination/balance issues, or changes in mental status.
CV: Sinus Tachycardia: Elevated heart rate. No chest pain, palpitations, edema, or syncope
RESP: Dyspnea: Shortness of breath. COPD Exacerbation: Increased dyspnea, cough, sputum production, wheezing.
Pulmonary Emboli: Dyspnea, chest pain, cough, hemoptysis.
No other respiratory symptoms reported
GI: No abdominal pain, nausea/vomiting, changes in bowel habits, appetite changes, or dysphagia.
GU: No urinary frequency, urgency, dysuria, hematuria, or urinary incontinence.
MUSCULOSKELETAL: No joint pain, muscle pain, stiffness, swelling, or limited range of motion.
INTEGUMENTARY: No skin changes, wound healing issues, pruritus, hair/nail changes, or excessive sun exposure.
2
Health Assessment
Physical Assessment:
HEENT
Head:
Normal head shape and size without palpable masses or tenderness.
Palpation: No tenderness or deformities noted.
Eyes:
Inspection: Conjunctiva pink and moist, pupils equal and reactive to light and accommodation (PERRLA).
Ocular Movements: Full range of motion without nystagmus.
Ears:
Inspection: External ear structures intact without erythema or discharge.
Otoscopic Examination: Tympanic membranes intact, no signs of infection or fluid.
Nose:
Inspection: Nasal mucosa pink, no evidence of nasal discharge or obstruction.
Throat:
Inspection: Oral mucosa moist and pink, no lesions or exudates. Uvula midline.
NEURO:
Alert and oriented to person, place, time, and situation (A&Ox4).
No signs of confusion or disorientation.
Cranial Nerves:
CN II-XII intact.
Motor Function:
Full strength bilaterally in all extremities.
No signs of tremors or involuntary movements.
Sensory Function:
Intact sensation to light touch, pain, and temperature.
Reflexes:
Deep tendon reflexes (DTRs) 2+ and symmetric throughout.
CV:
Inspection:
No visible pulsations or heaves.
Palpation:
Normal apical impulse palpated at the 5th intercostal space in the midclavicular line.
3
Peripheral pulses palpable and equal bilaterally.
Auscultation:
Heart sounds S1 and S2 heard, no murmurs, rubs, or gallops.
Sinus tachycardia present, heart rate 110.
Blood Pressure: 90/59
RESPIRATORY:
Inspection:
Use of accessory muscles noted.
Increased respiratory rate [specify].
No cyanosis or pallor observed.
Palpation:
Decreased chest expansion.
Tactile fremitus increased bilaterally.
Percussion:
Hyperresonance over lung fields.
Auscultation:
Diminished breath sounds, wheezing bilaterally.
Crackles or rhonchi may be present.
GI:
Inspection:
Abdomen symmetrical with no visible masses or distention.
Auscultation:
Normal bowel sounds in all quadrants.
Percussion:
Tympanic sound elicited over the abdomen.
Palpation:
Abdomen soft and non-tender to palpation.
GU: No complaints of dysuria or hematuria. No impaired urination or incontinence. Patient voids by ambulating to the bathroom with assisstance
MUSCULOSKELETAL:
Inspection:
Normal posture and gait.
No visible deformities or abnormalities.
Palpation:
No tenderness or swelling noted in joints or muscles.
Range of Motion:
4
Full range of motion in all major joints.
Strength Testing:
Muscle strength intact bilaterally.
INTEGUMENTARY:
Inspection:
Skin warm and dry.
No lesions, rashes, or signs of trauma.
Palpation:
Skin turgor normal.
No edema noted in extremities.
Pathophysiology (please write in your own words) – Cite References in APA format
5
Pathophysiology of COPD
Chronic Obstructive Pulmonary Disease (COPD) is a progressive respiratory condition marked by
persistent airflow restriction and respiratory symptoms such as dyspnea, coughing, and sputum
production. COPD's fundamental pathophysiology consists of chronic inflammation and airway
constriction, as well as lung parenchymal damage. This inflammation, which is commonly initiated
by exposure to irritating particles or gases, causes structural changes in the airways, such as
bronchial wall thickening and increased mucus production. Furthermore, the deterioration of
alveolar walls, known as emphysema, lowers the surface area available for gas exchange,
contributing to poor oxygenation and ventilation-perfusion mismatch. The ensuing airflow
restriction causes air trapping, hyperinflation of the lungs, and respiratory discomfort. It is
important to note that an imbalance between proteases and antiproteases in addition to oxidative
stress are significant factors that contribute to the development of COPD. These factors can
cause further damage to the lungs and lead to worsening symptoms. Effective management of
COPD involves addressing the primary goals which include managing symptoms, preventing
exacerbations, and improving quality of life through the use of bronchodilator medication,
pulmonary rehabilitation, and smoking cessation efforts (Global Initiative for Chronic Obstructive
Lung Disease (GOLD) in 2021).
Reference:
Global Initiative for Chronic Obstructive Lung Disease (GOLD). (2021). Global strategy for the
diagnosis, management, and prevention of chronic obstructive pulmonary disease (2021 report).
Retrieved from https://goldcopd.org/wp-content/uploads/2020/11/GOLD-REPORT-2021-v1.125Nov20_WMV.pdf
______________________________________________________________________________
Pathophysiology of Pulmonary Emboli:
A potentially fatal illness known as pulmonary embolism (PE) is caused by thrombi that clog the
pulmonary arteries; these thrombi usually result from deep vein thrombosis (DVT). The migration
of thrombi from the systemic venous circulation—typically the deep veins of the lower
extremities—to the pulmonary circulation, where they occlude pulmonary arteries, is a
pathophysiological aspect of pulmonary emboli. This blockage results in decreased blood flow to
the lungs, which raises the risk of hypoxemia, increased pulmonary vascular resistance, and
ventilation-perfusion mismatch (V/Q). Furthermore, vasoconstriction is triggered by the production
of inflammatory mediators and vasoactive chemicals in reaction to the emboli, which exacerbates
pulmonary hypertension. Patients may have a range of symptoms, from dyspnea and chest pain
to hemodynamic instability and cardiogenic shock, depending on the size and location of the
emboli. Prompt identification and treatment are necessary to reduce morbidity and mortality
associated with pulmonary embolism, which may include anticoagulant therapy and supportive
measures (Konstantinides et al., 2019).
Reference:
Konstantinides, S. V., Meyer, G., Becattini, C., Bueno, H., Geersing, G. J., Harjola, V. P., ... &
Zamorano, J. L. (2019). 2019 ESC Guidelines for the diagnosis and management of acute
pulmonary embolism developed in collaboration with the European Respiratory Society (ERS).
European Heart Journal, 41(4), 543-603. https://doi.org/10.1093/eurheartj/ehz405
Baseline vital signs
Current vital Signs
Temp: 37.5
Temp:36.6
BP:90/59
BP:102/80
HR:110
HR:75
RR:22
RR:18
SpO2:88 at room air SpO2:97 at room air
Pain:8/10
Pain:0/10
Frequency: Every 4 hours
____________________________________
Allergies/Side effects
NKDA
____________________________________
____________________________________
____________________________________
Diet with rationale: Diabetic Diet due to
medical history of Diabetes
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
Activity order: Ambulatory, Ambulates in
room and hall.
____________________________________
____________________________________
____________________________________
Limitations/prosthetic devices: No
limitations, no prosthetic devices
____________________________________
6
Include all Pertinent Laboratory
Data Results (normal and
abnormal)
PERTINENT LABORATORY
DATA Lab Test #1
___________________________
Hemoglobin:
___________________________
Include all Pertinent Laboratory
Data Results (normal and
abnormal)
PERTINENT LABORATORY
DATA Lab Test #2
___________________________
Sodium:
___________________________
Include all Pertinent Laboratory
Data Results (normal and
abnormal)
PERTINENT LABORATORY
DATA Lab Test #3
___________________________
Blood Urea Nitrogen
___________________________
Include all Pertinent Laboratory
Data Results (normal and
abnormal)
PERTINENT LABORATORY
DATA Lab Test #4
___________________________
Glucose
___________________________
Results: 12.5 g/dl (normal)
Normal values: 11.5 - 15.5 g/dL
Results:135mEq/L(normal)
Results:30mg/dL (high)
Results: 211mg/dL
Normal Values: 135-145 mEq/L
Normal values: 5-20mg/dL
Normal Value: 70-100mg/dL
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
Rationale of abnormal results
___________________________
___________________________
Rationale of abnormal results
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
Rationale of abnormal results
Kidney injury due to patient
comorbidities such as COPD,
diabetes, and PE. Medication
regimen can also cause kidney
injury.
Rationale of abnormal results
Patient blood glucose is elevated
due to Diabetic condition, stress
due to hospital admission or
disease.
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
INTRAVENOUS SOLUTION #1
Type: 0.9 Normal Saline
ML/HR 125ml/hr
Additives: None
Rationale for solution: For extracellular fluid replacement
___________________________
INTRAVENOUS SOLUTION #2
Type : N/A
_________________________________________________________
IV site: Left arm, medial antebrachial hep lock, 20G.
_________________________________________________________
7
INTRAVENOUS SOLUTION #3
Type N/A
INTRAVENOUS SOLUTION #4
Type N/A
8
MEDICATION
NAME
BRAND/GENERIC
CLASSIFICATION
Apixaban/Eliquis
Anticoagulant
DOSE /
ROUTE
ORDERED
TIMES
ADMINISTERED
RATIONALE FOR
ADMINISTERING
10mg/Oral
Twice daily
Treatment of
Pulmonary Embolism
Famotidine/Pepcid
10mg/mL
2mL IV push
twice daily
100U/mL
Inject 1U to 8U
Subcutaneously
daily
H2-histamine
receptor antagonist,
antiulcer agent
Insulin
Glargine/Lantus
THERAPEUTIC
RANGE FOR
AGE/WEIGHT If
Applicable
10 mg bid × 7 days,
then 5 mg bid
NURSING IMPLICATIONS
Required Patient
Education
Assess for bleeding, black
box warning for neurologic
status, abrupt
discontinuation, and
epidural, spinal anesthesia,
lumbar puncture
Skidmore-Roth, L.
(2024).
Mosby’s Drug
Guide for
Nursing
Students.
Elsevier.
Short-term treatment
for gastric ulcer since
patient is unable of
taking medication PO
IV 20mg 8-12hrs
Assess patient with ulcers or
suspected ulcers, assess
renal function, monitor I&Os
ratio BUN and Creatinine.
Instruct older adult patients
to avoid beers when taking
this medication.
Skidmore-Roth, L.
(2024).
Mosby’s Drug
Guide for
Nursing
Students.
Elsevier.
Treatment of
Diabetes
Onset 1.5 hr, no
peak identified,
duration ≥24 hr.
Assess: Fasting blood
glucose, urine ketones,
hypoglycemic reaction
during peak time,
hyperglycemia. Rotate cite
of administration
Skidmore-Roth, L.
(2024).
Mosby’s Drug
Guide for
Nursing
Students.
Elsevier.
Assess: Fasting blood
glucose, urine ketones,
hypoglycemic reaction
during peak time,
hyperglycemia. Rotate cite
of administration
Skidmore-Roth, L.
(2024).
Mosby’s Drug
Guide for
Nursing
Antidiabetic
≥6 yr: SUBCUT 10
international
units/day, range 2100 international
units/day, but may
go much higher
Insulin
Lispro/Humalog
Antidiabetic
100U/mL
Inject
Subcutaneously
as per Sliding
Scale
Treatment of
Diabetes
Onset 15-30 min,
peak ½-1½ hr,
duration 3-4 hr
≥3 yr: SUBCUT 15
min before meals;
continuous subcut
infusion (external
insulin pump) the
CITATIONS
9
total daily dose
should be based on
the insulin dose in
previous regimen
Prednisone/Rayos
20mg
1 tab PO daily
Decrease
Inflammation
5 to 60 mg per day
Assess for adrenal
insufficiency, nausea,
vomiting, confusion, and
hypotension. Monitor K+, BP,
weight, plasma cortisol
levels.
Caution not to discontinue
abruptly
Skidmore-Roth, L.
(2024).
Mosby’s Drug
Guide for
Nursing
Students.
Elsevier.
10mg
1 tab PO at
bedtime
Continue treatment of
Hypercholesterolemia
5-20mg per day
Assess diet and liver
function. Monitor renal
function. Assess for
rhabdomyolysis.
Skidmore-Roth, L.
(2024).
Mosby’s Drug
Guide for
Nursing
Students.
Elsevier.
5mg/5mL
Inject 5mL IV
push
Treatment of
hypertension, angina
5mg q2min x3
doses
Black box warning: Abrupt
discontinuation
Assess BP, edema, angina
Skidmore-Roth, L.
(2024).
Mosby’s Drug
Guide for
Nursing
Students.
Elsevier.
Corticosteroids
Rosuvastatin/Crestor
Antilipemic
Metoprolol/Lopressor
Antihypertensive,
antianginal, B1
adrenergic blocker
Students.
Elsevier.
10
DEVELOPMENTAL THEORIST:
CITE REFERENCES
Generativity vs. self-absorption and stagnation (middle age).
After the formation of an intimate relationship, an adult focuses on
helping future generations. The ability to broaden one's personal and
social involvement is essential throughout this period of growth.
Middle-aged people succeed in this stage by providing for future
generations through motherhood, teaching, mentoring, and
community involvement. Achieving generativity entails caring for
others as a fundamental strength. The inability to participate in the
growth of the following generation leads to stagnation. Nurses assist
persons who are physically unwell in developing creative approaches
to promote social development. Volunteering at a local school,
hospital, or church can provide a sense of fulfillment for persons in
their middle years.
Potter, P. A., Perry, A. G., Stockert, P. A., Hall, A., & Ostendorf, W. R. (2023).
Fundamentals of Nursing. Elsevier.
11
NURSING DIAGNOSES - NANDA
PLEASE DESCRIBE THE NURSING THEORY FIRST, THEN DESCRIBE RATIONALE
FOR PRIORITY ORDER BASED ON THE THEORY. (NEEDS NURSING THEORY)
LIST IN PRIORITY ORDER (BEGINNING WITH #1 IN PRIORITY)
1. Impaired gas exchange related to alveolar-capillary
membrane changes as evidence by SpO2 88% at room air
2. Decreased cardiac output related to obstructed pulmonary
artery as evidence by blood pressure of 90/65
3. Deficient Knowledge related to lack of understanding as
evidence by failure to follow with treatment and worsening of
condition
ASSESSMENT DATA
SUBJECTIVE/
OBJECTIVE/
CONTRIBUTING
FACTORS
NURSING
DIAGNOSIS
NANDA (North
American Nursing
Diagnosis
Association)
Virginia Henderson created the Nursing Need Theory to describe the distinct focus of
nursing practice. The approach emphasizes the significance of enhancing a patient's
independence in order to accelerate their progress in the hospital. Henderson's
approach focuses on basic human wants and how nurses might address them.
According to Henderson’s theory of needs, breathing as a basic physiological
requirement takes the highest urgency. Therefore, a priority nurse intervention is starting
supplemental oxygen as soon as possible.
As we address oxygenation, cardiac output will improve, and this will contribute to
patient being able to perform activities of the daily life such as eating and drinking,
eliminating body waist and move and maintain desirable posture which are 2nd, 3rd and
4th respectively in the 14 components of Henderson’s theory.
By educating patient in treatment adherence and in how to prevent and recognize
exacerbations the nurse will be helping patient to avoid dangers in the environment as
well as fostering learning, that constitute the 9th and 14th components on Henderson’s
theory. In addition will improve the patient’s lifestyle as treatment adherence will prevent
worsening of condition and disease progression.
PLAN
OUTCOME CRITERIA (CLIENT
CENTERED)
Must flow from Diagnosis and be
individualized
INTERVENTIONS
(NURSE CENTERED)
RATIONALE FOR
INTERVENTIONS
Cite References (APA)
EVALUATION
12
Subjective data:
Client self-report
shortness of breath and
difficulty breathing
Objective data:
respiratory
rate of 22 and SpO2 of
88% at room
1.Impaired gas
exchange related to
alveolar-capillary
membrane changes
as evidence by
SpO2 88% at room
air.
Short term goals:
The client SpO2 saturation will
increase from 88% to 92% within
2 to 5 min.
1. Administered
supplemental
oxygen therapy.
To improve oxygen perfusion
to tissue
The client will verbalize no
difficulty breathing within 2 to 4
hours.
2. Assess
respirations,
noting the
quality, rate,
rhythm, depth,
breathing effort,
and use of
accessory
muscles.
Patients' breathing patterns
will change over time to
enable gas exchange. Gas
exchange is affected by both
rapid and shallow breathing
patterns, as well as
hypoventilation. Shallow,
"sigh-less" breathing
patterns during surgery (due
to the effects of anesthesia,
discomfort, and immobility)
lower lung capacity and
ventilation. Hypoxia is
accompanied by indicators
of increased respiratory
effort.
Long term goals:
The client will ambulate without
showing signs of dyspnea.
The client will maintain a SpO2
above 95% at room air.
The client
SpO2
increased to
92% after 4
min of
supplemental
oxygen therapy
(Goal met)
The client
verbalized no
difficulty
breathing after
4 hours. (Goal
met)
Gulanick, M., & Myers, J. L.
(2022a). Nursing care plans:
Diagnoses, interventions, &
outcomes. Elsevier.
13
Subjective data:
The client self-report a
chest pain level of 7
using pain scale 0-10.
The client reports
weakness and
fatigue.
Objective data:
HR: 110
2.Decreased cardiac
output related to
obstructed
pulmonary artery as
evidence by blood
pressure of 90/65
Short term goal:
The client will report a pain level of
4 out of 10 within 30 min of pain
medication administration.
The client blood pressure will
increase close to normal values
(110/70) within the hour.
Long term goal:
The client will demonstrate
improved activity tolerance within
1-2 days.
1. Administered
ordered
medication and
start 0.9 % NS
bolus.
2. Assess HR and
BP.
3. Assess Hgb
Levels
IV fluid administration will
increase blood volume and
blood pressure.
Most patients experience
compensatory tachycardia
and significantly lower blood
pressure in response to
decreased cardiac output.
Older patients have a lower
reactivity to catecholamines,
therefore their response to
decreasing cardiac output
may be muted, with less
increase in HR.
BP: 90/59
Chest-CT scan results
show bilateral
Pulmonary embolism.
Fatigue and exertional
dyspnea are common
problems with low cardiac
output states. Close
monitoring of the patient’s
response serves as a guide
for optimal progression of
activity.
Report pain
level of 4 out of
10, 30 min after
medication
administration.
(goal met)
BP increased
to 108/77
within the hour
(goal met)
Demonstrate
activity
tolerance within
2 days (goal
met)
Gulanick, M., & Myers, J. L.
(2022a). Nursing care plans:
Diagnoses, interventions, &
outcomes. Elsevier.
14
Subjective data:
Client verbalized
symptoms started 1 week
prior to hospital visit.
Objective data:
Several re-admission to
the hospital in the last 6
months with same
conditions.
3. Deficient
Knowledge related
to lack of
understanding as
evidence by failure
to follow with
treatment and
worsening of
condition
Short term goal: client will
identify risk factors of their disease
within 1 day.
Client will participate in learning
process by the end of the shift
Long term goals:
The client will demonstrate the
proper execution self-care skills
such as insulin
administration/blood pressure
monitoring/etc.
The client will list signs and
symptoms that require immediate
intervention.
1.Assess motivation to
learn
2. Determine the client’s
self-efficacy to learn and
apply new knowledge.
4.Assess patient access to
learning resources,
medication coverage
and/or treatment
Learning demands energy.
Clients must recognize the
necessity or purpose of
learning. They have the right to
decline educational services.
The client's motivation drive
them to seek out potential
remedies and adhere to them in
the face of adversity.
Self-efficacy is a person's
confidence in his or her own
capacity to do a behavior. A first
step in teaching may be to instill
confidence in the learner's
ability to acquire the needed
information or abilities. People's
self-efficacy has a direct impact
on their ability to achieve their
goals. To improve selfmanagement of illness
processes, clients must have
increased self-efficacy and
believe in their ability to manage
their disease.
Client identified 3
risk factors of
their disease
within 1 day.
Client verbalized
willingness to
learn about
management of
his disease
before the end of
the shift.
Older adults may face additional
challenges in adhering to
therapeutic regimens, such as
increased sensitivity to
medications and their side
effects, difficulty adjusting to
change and stress, financial
constraints, forgetfulness,
insufficient support systems,
lifetime self-medication habits,
visual and hearing impairments,
and mobility limitations.
Gil Wayne BSN, R. N. (2023,
October 12). Knowledge deficit
& patient education nursing care
plan and management.
Nurseslabs.
https://nurseslabs.com/deficientknowledge/
15
Genogram:
Patient’s Father
Patient’s Mother
Patient
Son
The goal of the discharge plan is to ensure continuity of care after the patient leaves the hospital, and to prevent hospital readmission. Patient
teaching enhances patient compliance with discharge planning.
16
Discharge Plan / Patient Teaching:
Patient will be provided an explanation and reinforce explanations of the individual disease process.
Patient will be educated in how to identify individual factors that may trigger or aggravate conditions (excessively dry air, wind, environmental
temperature extremes, pollen, tobacco smoke, aerosol sprays, and air pollution).
Patient will be educated about activity limitations and alternating activities with rest periods to prevent fatigue; ways to conserve energy during
activities (pulling instead of pushing, sitting instead of standing while performing tasks); use of pursed-lip breathing, side-lying position.
Patient will educated in the proper technique and demonstrate techniques for using a metered-dose inhaler (MDI), insulin pen and incentive
spirometer.
Patient will follow up with Primary Care Provider within 7 days of discharge.
Patient will continue diabetic diet at home.
Patient will comply with treatment regimen and will attend follow up visits.
References:
Gil Wayne BSN, R. N. (2023, October 12). Knowledge deficit & patient education nursing care plan and management. Nurseslabs.
https://nurseslabs.com/deficient-knowledge/
Gulanick, M., & Myers, J. L. (2022b). Nursing care plans: Diagnoses, interventions, & outcomes. Elsevier.
Potter, P. A., Perry, A. G., Stockert, P. A., Hall, A., & Ostendorf, W. R. (2023). Fundamentals of Nursing. Elsevier.
17