College of Nursing and Health
ACNP Program
Weekly ACNP Clinical Log
CLINICAL FACULTY:
Student:
Beth Croucher
Teresa Siefke
Course / Quarter / Year:
Date
1
Diagnosis
F
M
Age
Clinical Site: Miami Valley Hospital-Critical Care
Preceptor: Johnnie Dillinger, ACNP-BC
 Each week, complete this document
each date, make an entry for every patient you see.
Wk  For
There may be multiple entries for the same patient, i.e., a long-term patient in your caseload
___
would be listed again for each date.
 Under comments, list any procedures performed, or other pertinent information.
2/7
Facial swelling
X
2/7
Pancreatitis
2/7
ST depression, hypotension
X
6
2
Angioedema. Intubated with failed extubations x 3. Surgery consult for tracheotomy
2/7
Hypokalemia, colitis, lymphadenopathy
X
6
1
2/7
Near syncope
2/7
Acute respiratory failure
X
6
8
2/7
Septic shock
X
5
4
2/7
Unresponsive, respiratory failure, found down
X
6
7
2/7
Respiratory failure, COPD
X
7
8
2/8
Facial swelling
2/8
Pancreatitis
X
2/8
Cardiac arrest, MVC
X
X
2
3
4
X
5
7
2
6
7
8
9
1
0
1
1
1
2
Comments / Activities
X
6
8
Alcohol abuse with pancreatitis. Now extubated. Remains confused. Tolerating minimal
duodenal feedings with NG to LIWS
Cardiac cath 2 days prior was without coronary occlusion. Demonstrated LAD bridge.
Remains Hypotensive requiring vasopressor
support.
Pan cytopenic. Respiratory failure, mechanical
ventilation. Renal failure requiring CRRT.
Near syncope without fall. c/o R leg pain, ortho evaluated as hamstring sprain and not
fracture. Anemia of unknown etiology.
Morbid obesity with noncompliance with
home medications. Acute on chronic respiratory failure with difficult to wean vent.
Changed to Bumex IV TID for aggressive diuresis
Feeling ill with diarrhea for 3-5 days prior to
presentation. Septic shock, fluid resuscitation,
blood and urine cultures pending. Broad spectrum antibiotics (Vancomycin, Zosyn,
Levaquin)
Transfer from outside hospital after being
found down, unresponsive, questionable seizure. Mechanical ventilation. Improving neurologic status, appropriate to extubate.
Mechanical ventilation, IV steroids, empiric
antibiotics
Trach placed overnight d/t significant facial
swelling and multiple failed attempts at extubation.
Pancreatitis slowly resolving. Tolerating duodenal feedings, NG to LIWS. Transfer out of
ICU
MVC found by police & paramedics to be in
cardiac arrest. CPR & shocked. Hypothermic
protocol initiated
E/M
Code
1
3
2/8
Acute on chronic respiratory failure
x
6
8
2/8
Septic shock
X
5
4
2/8
Unresponsive, respiratory failure, found down
X
6
7
2/8
Respiratory failure, COPD
X
7
8
2/8
Failed kidney transplant, initiation of HD
X
5
7
2/24
Sepsis, acute respiratory failure
2/24
CHF
2/24
1
4
1
5
Improved UO with bumex. FiO2 weaned to
50%, increased pressure support to 20. Tolerating well.
Septic shock with AKI. Continue maintenance
fluids. Consult Renal d/t no improvement in
renal function after fluid resuscitation. blood
cultures with G+ cocci resembling staff.
Broad spectrum antibiotics (Vancomycin,
Zosyn, Levaquin)
Extubated yesterday, doing well on RA. Hypotensive, fluid bolus given. Somnolent but
awakens easily.
Mechanical ventilation, IV steroids, empiric
antibiotics. CPAP trials, tolerating well today.
6
2
Afib/aflutter started on heparin gtt. Overnight
developed rectus abdominis hematoma and
acute anemia. Received 4 units RBCs overnight. Levophed for hypotension.
Found to have leukemia upon admission w/u.
Failure to wean, remains severe septic shock
X
6
1
Significant cardiac history, has AICD. Continue
to diurese. Pending f/u ECHO.
Cirrhosis, liver failure
X
6
4
2/24
Fall at home, c2 fracture, severe AS, evaluation
for TAVR
X
7
7
2/24
Fever, infection
X
5
9
3/3
Respiratory failure, sepsis
X
6
2
Platelet count 14, end-stage liver disease.
Consulted hospice and discussed withdrawal
of care.
Severe AS and pending TAVR. Has dental abscess being treated and gangrene of toe. Has
c2 fracture that needs surgery, but infection
and cardiac status complicate both surgeries
(spine and TAVR)
Splenic abscess, with drainage. Needs nutrition but GI not ready to use enteral route. Discuss need for TPN.
Sepsis, newly diagnosed leukemia. Respiratory failure with mechanical ventilation.
3/3
Hypotension
X
6
5
Hypotension, fluid resuscitated. Now off pressors. Transfer to hospitalist service.
3/3
Acute on chronic respiratory failure, COPD exacerbation
X
5
8
SBT as tolerated. ECHO with EF 20-25%.
3/3
Encephalopathy
6
8
3/3
Hypotension, shock, AKI
Metabolic encephalopathy, respiratory failure
requiring mechanical ventilation. Unclear
cause of mental status.
AKI 2nd dehydration, hypotension. Fluid rescusitation and improving BP & renal function
3/3
AKI, hyperkalemia
3/3
Acute respiratory failure 2nd CHF exacerbation
3/3
Cardiac arrest
3/3
Acute respiratory failure, OSA
3/3
Cardiac arrest, hypothermic protocol
X
X
X
4
8
X
8
6
Received cancer treatments outpatient. AKI
likely 2nd tumor lysis. Kayexalate, dextrose,
insulin, calcium. No indication for dialysis.
No extubated. Transfer out of ICU and transfer
to hospitalist service.
6
1
Without neurologic recovery s/p arrest. Family decision to w/draw care.
X
3
5
X
3
8
Morbid obesity with untreated OSA. Acute
respiratory failure with mechanical ventilation. Without evidence of infection. ARDS with
refractory hypoxemia.
No clear indication for cardiac arrest. TNI not
significantly elevated, no cardiac history, no
medical history, no home meds, current
X
X
6
1
5
3
smoker. ECHO pending, serial cardiac enzymes. Cardiology consulted, hypothermic for
24 hours.
Sudden SOB, found PEA with CPR & 2 epi.
?seizure-like activity. Started Keppra, ECHO
pending, cardiac enzymes pending.
ESRD on dialysis, difficult to dialyze d/t drops
BP. EF ~10%. Mechanical ventilation
X
8
8
Rate controlled, normotensive, will sign off.
Transfer care to hospitalist and/or cardiology
X
6
6
Failure to wean, pending trach & peg vs palliative care. Awaiting family decisions.
7
4
5
4
Hyponatremia 2nd fluid overload from CHF.
Remains on 2 pressors. Needs further diureses for HF.
Extubated to BiPap. Added steroids. Blood
cultures negative.
X
4
2
Cirrhosis, likely variceal bleeding. GI consulted.
Colostomy and enterostomy complications
X
6
0
3/5
Acute renal failure, encephalopathy
X
6
2
Multiple chronic medical problems including
chronic pancreatitis, adrenal insufficiency, RA,
and bowel ischemia.
LP with pending cultures, ? HSV encephalitis.
AKI 2nd dehydration, shock.
3/5
Acute on chronic respiratory failure
X
7
5
Aspiration pneumonia. Extubated, needs PEG
d/t recurrent aspiration.
3/5
Myelodysplasia
X
6
3
Leukapheresis.
3/10
Cardiac arrest
X
4
8
Consult palliative care. Remains on ventilator
but no neurologic improvement.
3/10
Cardiac arrest
X
3
8
3/10
CHF with acute on chronic respiratory failure
X
7
1
EEG did not demonstrate seizures. Continues
to have myoclonic jerks. Discussion with procurement for organ donation
On bumex drip for dieresis. Chronic afib, hold
Coumadin d/t supratherapeutic INR
3/10
GIB, cath with MVD, needs CABG
3/10
ESRD, ischemic bowel, s/p open resection
3/10
Encephalopathy
X
6
8
3/10
Myelodysplasia
X
6
3
3/10
Facial edema, infection, s/p tooth extraction
X
6
5
3/11
Cardiac arrest
X
4
8
3/3
MVA, found PEA arrest
X
3/3
ESRD, shock, respiratory failure
3/5
Afib with RVR, hypotension
3/5
Sepsis, C2 fracture, respiratory failure
3/5
Chronic systolic HF
3/5
Acute on chronic respiratory failure
X
3/5
Upper GI bleed
3/5
7
4
X
X
X
X
5
3
7
3
EGD demonstrated ulcers with clots, did not
band as were note bleeding. Needs CABG, but
is high risk with coagulopathy r/t ETOH and
liver disease. On octreotide drip. Continue
CIWA
Remains mechanically vented requiring pressor support. Unable to tolerate HD and was
started on CVVHD. Unable to close abdomen
d/t edema
Decline in ADL and MS over several years. No
clear explanation for decreased
MS/encephalopathy. Remains failure to wean
from vent
s/p leukapheresis. Ready to transfer to floor.
Overall prognosis is poor.
Tooth extraction 5 days prior, non-compliant
with PO antibiotic. Significant facial swelling
with tracheal deviation. Concern for necrotizing fasciitis. To OR for drainage.
Arranging family meeting to determine goals
of care. No neurologic improvement.
3/11
Admitted to floor with HA and fevers. Transferred to ICU d/t no improvement. Sepsis,
acute respiratory failure
X
5
1
3/11
Cardiac arrest
X
3
8
3/11
GI bleed, pending CABG
3/11
ESRD, ischemic bowel, s/o open resection
3/11
Encephalopathy
X
6
8
3/11
Idiopathic pulmonary fibrosis
X
8
3
Remains vented on CVVHD and pressors. Will
return to surgery for closure soon. Evaluations daily d/t edema
Discuss with family goals of care. Pt has made
little improvement and sill no explanation for
mental status. Worsening edema and renal
function
Transfer from outside hospital for acute on
chronic respiratory failure.
3/12
Cardiac arrest
X
4
8
Family meeting planned today. Possible medical extubation and transfer to hospice.
3/12
Sepsis, acute respiratory failure
X
5
1
3/12
HCAP
3/12
Cardiac arrest
3/12
CHF exacerbation, acute on chronic respiratory
failure
3/12
CHF, acute on chronic respiratory failure
3/12
AMI, cardiac arrest
X
6
8
Multiple cultures pending, including rare and
unlikely organisms. Everything to date has
been negative. Still requires high amount of
vasopressor support and worsening renal
function
Metastatic cancer. Pleural effusions and
pneumonia. Limited treatment measures. Pt
wants hospice.
Family decided to pursue organ donation.
Plan withdrawal of care and donation tomorrow.
ECHO pending. On dobutrex drip, high-dose
diuretics, remains on high FiO2 and PEEP to
maintain oxygenation
UTI positive on admission, recheck UA. Worsening renal failure. No indications for acute
dialysis.
Cardiac arrest with immediate bystander CPR.
2 DES to LAD, IABP, and ventilator support.
3/12
GI bleed, pending CABG
X
5
3
3/12
ESRD, ischemic bowel, s/o open resection
3/12
GI bleed, NASH
X
4
5
3/12
Idiopathic pulmonary fibrosis
X
8
3
3/12
Abdominal pain, sickle cell crisis
X
4
4
Sedation vacation and SBT. Discuss with pt
and wife about goals of care. Underlying disease process has overall poor prognosis and
intubation is not helpful long-term. Discuss
extubation and no reintubation. Pt was extubated and doing well.
Transfer from floor requiring intubation and
erythroparesis for sickle cell crisis.
313
Cardiac arrest
4
8
Family discussion of w/draw of care. Will
transfer to hospice if does not pass quickly
X
X
7
3
X
X
6
4
3
8
X
X
7
4
7
1
X
X
5
3
7
3
May require intubation d/t fatigue and for
airway management. W/u for septic sources.
LP done and negative. Blood cultures NGTD.
Empiric antibiotics and fluid resuscitation.
Remains unresponsive and without neurologic improvement. No clear cause for arrest.
Presumptive viral myocarditis.
Remains on CIWA with protonix and ostreotide for upper GI. Pending CABG on 3/13
Remains on CIWA with no evidence of DT.
Pending CABG on 3/13. Remains stable and
good mentation, no s/s of bleeding.
Remains vented on CVVHD and minimal pressors. SBT and respiratory vitals. Borderline,
RVs and d/t planned return to surgery will
remain vented.
Serial H&Hs. Hb 6.8, received 2 PRBCs. Awaiting recheck.
3/13
Fevers, sepsis, acute respiratory failure
3/13
HCAP
3/13
Cardiac arrest
3/13
CHF exacerbation, acute respiratory failure
3/13
ESRD, ischemic bowel, s/o open resection
3/13
AMI, cardiac arrest
3/13
CHF, acute on chronic respiratory failure
3/13
Idiopathic pulmonary fibrosis
3/16
AMI, thrombectomy and PCI
3/16
Cardiac arrest, s/p DES x 2 to LAD
3/16
Fever of unknown origin, sepsis
3/16
HCAP & metastatic cancer
3/16
CHF exacerbation
3/16
X
5
1
X
X
6
4
3
8
Worsening renal function, metabolic acidosis,
consult to renal. Presumption of toxic shock
d/t no evidence of infectious source..
Pleural effusions, possible thoracentesis.
5
7
Withdraw of care today. To OR for w/draw
and possible organ donation. She did not pass
within the hour window and returned to the
room. She passed 2 hours later. Will remain a
tissue and eye donor.
SBT and ABG. Remains on dobutrex with highdose dieresis. RVs are good, ABG acceptable,
may have trial extubation to BiPap
Remains vented on CVVHD. SBT but remain
vented d/t return to surgery for closure
planned tomorrow.
Cardiac arrest with immediate bystander CPR.
2 DES to LAD, IABP, and ventilator support.
Extubated and doing well. Transfer out of ICU.
Worsening renal failure. No indications for
acute dialysis. Possible ileus. Afib but hold
cardizem drip d/t low BP.
Extubated yesterday. Code status changed
with no reintubation. Doing well and can
transfer out of ICU.
s/p thombectomy, DES t LAD, EF 30-40%. R
leg & R UE DVT
6
8
Transferred to floor last week. Up and walking, developed acute BL PE
5
1
Still no answers as to source of infection. Acts
like toxic shock. Slowly clinically improving.
6
4
d/c home with hospice today.
X
7
3
TAVR
X
8
5
s/p aspiration with immediate bronch. Progressive worsening over the weekend requiring intubation, rotoprone, and began CVVHD
Remained on ventilator s/p TAVR. SBT and
RVs. Possible extubation today.
3/16
ESRD s/p ischemic bowel resection
X
7
3
3/16
CAD with OSA
X
6
3
3/20
Acute on chronic CHF
X
8
0
3/20
Fever of unknown origin
3/20
CHF exacerbation
3/20
CHF with acute on chronic respiratory failure
X
7
3
3/20
AS s/p TAVR
X
8
5
X
X
7
4
7
3
X
X
6
8
7
1
X
X
X
X
X
X
8
3
5
1
X
7
4
Brady arrest, with ACLS. On epinephrine drip,
levophed, vasopressin. Continues with CVVHD
without fluid removal, ventilator support.
Questionable neurologic status.
Evaluate for BiPap rather than CPAP at home.
Ok to transfer to floor.
Mechanical ventilation, on neosynephrine.
Transition to levophed rather than neo. Not
ready for extubation.
Now off pressors, SBT daily. Still not quite
ready to extubate. Transfuse platelets and
RBCs.
Extubated to Bipap for a couple days. Reintubated. Continue dieresis but is likely at
end stage CHF and cardio-renal syndrome
Remains on rotoprone with CVVHD. Showing
improvements with oxygenation in prone position. Will trial prolonged periods supine.
Delerium. Extubated and weaning oxygen.
Increase mobility as tolerated. PT/OT
3/20
ESRD s/p ischemic bowel resection
X
7
3
3/20
Syncope
3/20
Overdose, suicide attempt
X
4
5
3/20
Failure to wean, planned trachestomy
X
5
8
3/20
Altered mental status
X
4
9
X
6
8
Minimal neurological responses. Possible CVA
but too unstable for head CT. Continue
CVVHD, pressors, & vent management. Bronch
for possible mucus plugging. Noted patchy
erythema down bronchioles suspicious for
viral etiology
Pancreatic cancer s/p gamma knife laser radiation and current chemotherapy. Now with GI
bleed and Hb 4.6 on admission. Transfuse
RBCs and fluid resuscitation for SBP >90
OD on multiple drugs including TCA. Prolonged QT interval. On sodium bicarbonate
drip with serial EKGs.
Prolonged vent time with need for BiPap and
LTAC. Failure to wean and admitted for
planned trach. Due to refractory hypoxemia
trach was cancelled. On nitric oxide and high
FiO2 and PEEP for oxygenation.
Long medical history. Intubated for acute respiratory failure. Possible extubation today. MS
is a concern d/t does not follow commands
and unsure of ability to clear secretions.
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