Client’s Initials
J.F.
Date of Care:
Occupation:
11/20/22
Homeless and no occupation.
Age:
46
Sex:
m
Role in family:
Race:
African
American
Religion:
unknown
Erikson’s Stages in Life
Cycle
No family present, no family
listed as emergency contacts
on prior hospital visits and
patient has been unconscious
since admission to BT.
Middle adulthood,
Generativity vs. Stagnation
Primary language:
English
11/3/22
Admission date:
Chief complaint:
Assault victim, head injury
and bleeding/bruising
Additional Diagnosis:
Allergies:
History of Present Illness
(Sources: Patient, Chart,
Family/Caregiver)
Past Medical History:
Past Surgical History:
Patient was initially admitted
to LBJ for DX of sepsis and a
DX of polysubstance
overdose. Patient was then
transferred to BT when he
was an assaulted at LBJ &
received a head injury.
Sepsis, GI bleed, Hepatic cirrhosis altered mental status, acute respiratory failure,
elevated LFTs, portal hypertension, encephalopathy due to ammonia, and pneumatosis
intestinalis of large intestines.
Admission Diagnosis:
Aspirin
Alcoholic cirrhosis of liver with ascites, thrombocytopenia, poly substance abuse
Source: Patients chart from prior admissions.
Alcoholic cirrhosis of the liver, poly substance abuse and umbilical hernia without
obstruction.
HX of a prior 2020 surgical layered wound closure due to a dog bite of the calf.
Family History:
Maternal hypertension and paternal diabetes.
Psychosocial History
Pt tested positive for cocaine, alcohol, tobacco, and other unknown substances. Pt chart
states he smokes 3 packs per day. Pt. is a single and homeless male with no known
family. The hospital chaplain is currently approving all emergency procedures for this
patient while unconscious.
RNSG 2361
Name
Med/Surg II
NURSING PROCESS FORM: PART I
PATHOPHYSIOLOGY OF CURRENT DIAGNOSIS FROM TEXTBOOK
Diagnosis and Definition of Diagnosis
Sepsis is an extreme and life-threatening conditions causes by infections to the body cause by an unknown organism.
Infection enters the body and causes a multifaceted response and reaction through the body. Infections typically start in
the lungs, urinary tract, skin, or GI. Then without effective treatment led to tissue damage, organ failure and death. 30%
of all patients with die. Sepsis and septic shock have a high incidence worldwide, with a mortality rate of 25% or
higher.
Polysubstance use is the use of more than one drug. This could be an intentional like in the form of street drugs where a
person is trying to increase the effects of one drug with another. Or it could be unintentional in the case of senior
citizens with fading memories who mix and match drugs unintentionally. Intentional or unintentional the effects can be
deadly. In the case of the patient, he was a street drug user that test positive for atleast alcohol, cocaine and fentanyl.
A head injury includes a variety of injuries or traumas to the skull, scalp, brain and under lying tissue and blood vessels
in the head. A serious injury can is a traumatic brain injury, and a mild injury can be small contusion. It was not clear in
the case of the patient which diagnosis was causing him the most problem, unresponsiveness and an ICU stay. There
was no noticeable erythema or contusions marking his skull, or scalp at the time of clinical. However, head injury can
have a potential for poor outcome and changes in mental status. Death can occur from the direct injury or hemorrhage
and shock. It is important to seek medical attention following all head injuries.
Etiology
“Sepsis is the systemic inflammatory response syndrome (SIRS) is defined by the presence of two or more of the
criteria ( T >38C, HR >90, RR >20, WBC >12K) . When SIRS results from an infection, the clinical diagnosis is sepsis.
A positive pathogen culture is not necessary to establish sepsis if there is a strong clinical suspicion of an infection
{such as finding neutrophils in a normally sterile environment (e.g., the peritoneum)]. Severe sepsis occurs when the
septic process has become so severe that at least one organ has become dysfunctional, and septic shock refers to
hypotension due to severe sepsis. In order of severity: Septic shock is worse than severe sepsis, which is worse than
sepsis” source:(Stearns-Kurosawa, 2011).
Polysubstance abuse is a multifaceted explanation. No one factor or set of is proven to cause substance use. Instead,
there are risk factors. Genetics make up 40 to 60% of risk for addiction. Race and gender can be a risk factor as well.
Males, Native American and Caucasian populations are more at risk than Asian’s. People with neurodivergent
diagnoses like ADHD, ODD, and impulsive traits are at a higher risk for substance abuse. Additionally, there are
environmental risk factors like at risk communities and low socio-economic status. Source: (Hopkins, 2022)
“In general, head injuries can be divided into two categories based on what causes them. They can either be head
injuries due to blows to the head or head injuries due to shaking. Head injuries caused by shaking are most common in
infants and small children, but they can occur any time you experience violent shaking. Head injuries caused by a blow
to the head are usually associated with motor vehicle accidents, falls, physical assaults and sports-related accidents” In
the case of the patient he sustained a head injury from assault. Source: (Reed-Guy, 2018)
Diagnostic Procedures
The patient received an endoscopy while present for clinical 11/5/22 the endoscopy revealed healing ulcers and varices.
This was good news regarding the patients DX of a GI bleed.
Signs, Symptoms, and Course of the Disease/Disorder
Signs and symptoms of sepsis include loss of consciousness, severe breathlessness, a fever or low body
temperature, change in mental status, slurred speech, cold clammy or molten skin, fast heartbeat, chills and
shivers, severe muscle pain, feeling dizzy or faint, nausea and vomiting, and diarrhea.
RNSG 2361
Name
Med/Surg II
Signs and symptoms of polysubstance abuse include pupils larger or smaller than usual, changes in appetite,
sleep pattern and physical appearance, unusual smelling breath or body odor, loss of coordination or mental
cognition.
Signs and symptoms of a head injury include loss of consciousness, headache, vomiting and nausea,
convulsions and seizures, dilation of 1 or both pupils, clear fluid or drainage from nose or ears, and inability
to waken from sleep
Reference (APA Format with pages numbers-Reference within last 5 years)
Centers for Disease Control and Prevention. (2022, August 9). What is sepsis? Centers for Disease Control
and Prevention. Retrieved November 23, 2022, from https://www.cdc.gov/sepsis/what-is-sepsis.html
Centers for Disease Control and Prevention. (2022, February 23). Polysubstance use facts. Centers for
Disease Control and Prevention. Retrieved November 23, 2022, from
https://www.cdc.gov/stopoverdose/polysubstance-use/index.html
Etiology: What causes addiction? Recovery Research Institute. (2019, June 17). Retrieved November 23,
2022, from https://www.recoveryanswers.org/addiction-101/etiology-what-causes-addiction/
Gil Wayne, B. S. N. (2022, March 19). Ineffective airway clearance – nursing diagnosis & care plan.
Nurseslabs. Retrieved November 23, 2022, from https://nurseslabs.com/ineffective-airway-clearance/
Gil Wayne, B. S. N. (2022, March 19). Ineffective coping – nursing diagnosis & care plan. Nurseslabs.
Retrieved November 23, 2022, from https://nurseslabs.com/ineffective-coping/
Head injury. Head Injury | Johns Hopkins Medicine. (2021, August 8). Retrieved November 23, 2022, from
https://www.hopkinsmedicine.org/health/conditions-and-diseases/head-injury
Kizior, R. J., & Hodgson, B. B. (2000). Saunders Drug Handbook for Health Professionals 2000. W.B.
Saunders Co.
Lewis, S. M., Bucher, L., Heitkemper, M. M., Harding, M., Barry, M. A., Lok, J., Tyerman, J., Goldsworthy,
S., & Lewis, S. M. (2019). Medical-Surgical Nursing in Canada: Assessment and management of
clinical problems. Elsevier.
Matt Vera, B. S. N. (2022, March 18). 8 liver cirrhosis (hepatic cirrhosis) nursing care plans. Nurseslabs.
Retrieved November 23, 2022, from https://nurseslabs.com/8-liver-cirrhosis-nursing-care-plans/2/
Matt Vera, B. S. N. (2022, March 18). 8 liver cirrhosis (hepatic cirrhosis) nursing care plans. Nurseslabs.
Retrieved November 23, 2022, from https://nurseslabs.com/8-liver-cirrhosis-nursing-care-plans/3/
Reed-Guy, L. (2018, September 29). Head injury: Types, causes, and symptoms. Healthline. Retrieved
November 23, 2022, from https://www.healthline.com/health/head-injury#causes
Sepsis. NHS inform. (n.d.). Retrieved November 23, 2022, from https://www.nhsinform.scot/illnesses-andconditions/blood-and-lymph/sepsis
RNSG 2361
Name
Med/Surg II
Stearns-Kurosawa, D. J., Osuchowski, M. F., Valentine, C., Kurosawa, S., & Remick, D. G. (2011). The
pathogenesis of sepsis. Annual review of pathology. Retrieved November 23, 2022, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684427/
RNSG 2361
Name
Med/Surg II
KARDEX WORKSHEET INFORMATION
Description
*Vital signs
Vital signs Frequency
Q6hrs.
Vitals at 0900:
BP: 96/64
HR: 64
RR: 16
T: 93.5
O2: 100
BS: 114
Weight (kg)
71.2 kg
*I&O (ml)
Intake: patient received 3100ml of fluid via various IVs throughout the day
Output: was 30ml per hour
Indwelling catheter due to unconscious state
*Urinary Elimination
*Bowel Elimination
NG tube
*Diet
*Positioning or Turn
*Bath Type
*Activity Level
Dressing
Change/Site
Orthopedic Device/Care
Scheduled Procedures
Pt was not eliminating feces at this time and had not since admission. Last bowel
movement was at LBJ hospital prior to admission and reported as melena. There was
pending order for a rectal tube to be placed for the PT due impaction. Pt has also had
no food or TPN since admission 2 days ago. Pt was approved to start TPN later this
evening after the rectal tube was in place.
N/A
Currently the patient is not eating and has not been given any form of nutrition since
admission. The patient is approved to start TPN later this evening.
The patient was not turn today per the PHCP request. The MD stated he was not stable
enough to turn at this time however he will resume Q2 hours once he stabilizes.
A bed bath would be this patient only option at this time in ICU. BT ICU is actually
not equipped with restrooms or showers in the ICU.
Bed bound.
No dressings were present to change at this time. A right atrial line was place during
the clinical visit that will need changed per the hospitals policy in the future.
N/A
BMP, Lactic acid, Liver profile and CBC
O2 at L/Min via:
Mechanical vent.
EKG Monitoring
Continuous monitoring in ICU
I.V. Fluid Type
Patient was rotating lactated ringers and normal saline
I.V. Site/rate
(Hep Lock IV)
*Allergies
Patient had a rt atrial line in the radial artery. Pt also has left radial IV line.
Code Status
Isolation Status
Allergy to Aspirin
FULL
Standard
* Required Critical Information
RNSG 2361
Name
Med/Surg II
NURSING PROCESS FORM: PART I
SUBJECTIVE/OBJECTIVE ASSESSMENT
Overall Appearance: [i.e. Posture, expression, first impressions]







Pt. is a African American male lying in bed/Fowlers position (30 º) wearing a hospital gown. Pt is unconscious
and on mechanical ventilation.
Pts appearance is consistent with charted age.
Face was round, smooth, and symmetrical. Hair grayish black, clean, and evenly distributed.
Tattoo’s present in various locations including tattooed tear drops on his face.
Pt. appears malnourished, with a distended abdomen.
Pt. has no odor of perspiration despite being deem homeless.
Absence of facial droop, ticks, or tremors.
Integumentary [i.e., skin undertone, turgor, edema, warmth, wounds etc.]












Skin color is appropriate for race and even.
Skin has pink undertones, warm, dry and intact.
Skin turgor: returned to original state.
Edema noted on RLE and LLE: 2+
Nails are hard, smooth, and immobile. Nailbeds pink with no clubbing. Cuticles smooth, no detachment of
nail plate. Dirt is present under the nails bilaterally. The Capillary refill < 3 sec
No visible wounds present on the patient.
EENT [i.e., eyes, ears, nose or sinus problems, swallowing difficulties, dental or oral problems]
Eyebrows: Hair is evenly distributed. Eyebrows are symmetrically aligned and showed equal movement when
grimacing during suction. Eyelashes appeared to be equally distributed and curled outward.
Eyes: pinpoint pupils that do not react to light (and unable to accommodate). Eyelids in normal position with
no abnormal widening or ptosis. No presence of redness, discharge, or crusting noted on lid margins. Facial
tattoos near the eyes. Conjunctiva and sclera appear moist and smooth. Sclera is white with no lesions or
redness. No swelling or redness over lacrimal gland noted. Per chart findings: Irises are round, flat, and evenly
colored.
Ears: are equal in size bilaterally. Auricles are aligned with the corner of each eye. Skin is smooth, with no
lumps, lesions, or nodules. No discharge noted. Hearing intact according to chart. Absence of hearing devices.
Nose: Appeared symmetric, straight, and uniform in color. No presence of discharge or flaring.
Lips are moist without lesions or swelling.
Jaw is aligned with no deviations observed.
Gastro-Intestinal [i.e. bowel sounds, appetite, weight gained or lost, elimination pattern, nutritional supplements, date
of last bowel movement]




Last BM was prior to admission at LBJ hospital. Stool soft and melena. Pt has a suspected GI bleed.
Abdomen is distended and hard. New order pending for a rectal tube due to suspected impaction.
Bowel sounds are not present and hypoactive currently.
Diet: Currently the patient is not eating and has not been given any form of nutrition since admission. The
patient is approved to start TPN later this evening.
Neurological [i.e. pain and its perception, last hearing or visual check, LOC, papillary response, signs of conduction
deficits, speech pattern, orientation]:




Pt is unconscious and grimaces to painful stimuli and suctioning.
Pt is not responsive to voice.
No presence of hearing aids noted.
No presence of sight aids. Pupils are pinpoint size and not reactive to light.
RNSG 2361
Name
Med/Surg II
Reproductive [i.e. last breast or testicular self-examination, mammogram, pelvic or prostate exam, LMP, pain]
Male: external genitalia
Not Observed and patient is unable to verbalize about last exam.
Renal [i.e. elimination route, color, clarity, and odor of urine, discharge, 24-hour production, & findings of current
urinalysis]


Patient currently is utilizing a indwelling catheter. And voiding an average of 30 ml per hour.
Urine clear and pale yellow, no foul smell.
Pulmonary [i.e. tobacco history, shortness of breath, breath sounds, rate, rhythm, cough,]





Pt. is currently on a mechanical vent due to acute respiratory failure.
Clear advantageous bilateral breath sounds. RR 18 at 1000.
Respirations are even and unlabored.
Chest expansion is symmetrical.
No Hx of asthma or tuberculosis.
Endocrine [i.e. diagnosed at what age, last HgbA1c or associated lab work, BS ranges, compliant, thyroid]


Pt does not have a current dx of diabetes only a family history of diabetes.
Blood sugar was 114 while on shift.
Musculo-Skeletal [i.e. mobility, safety, range of motion, atrophy or edema, prosthetic]:




Gait: Unable to assess. Patient is unconscious and confined to bed with a mechanical vent.
Pt has passive ROM of BLE. However no active ROM could be assessed due to patient’s unconscious state.
Absence of prosthetics.
Edema is present 2+ BLE
Heart rate & rhythm
Cardiovascular
64 RRR (right arm, lying) @ 1000.
Blood pressure
96/64 (Right atrial, lying) @ 1000.
Point of maximal impulse
(apical pulse)
Auscultated at the fifth ICS (intercostal space) at the left MCL (midclavicular line)
Clear without murmurs. No S3 or S4 heard.
Adventitious sounds
None noted
Pulse rhythm & quality
[scale 0-4]
Right Lower
extremity
Left Lower
extremity
Right Upper
Extremity
Left Upper Extremity
Dorsalis pedis
+2 Moderate
pitting
+2 Moderate
pitting
-
-
Posterior tibial
+2 Moderate
pitting
-
+2 Moderate
pitting
-
-
-
+2 Moderate
pitting
+2 Moderate
pitting
Radial
RNSG 2361
Name
Med/Surg II
Edema
+2 Moderate pitting
Capillary refill
<3 seconds
Pulse deficit [if
applicable]
N/A
Twelve Lead ECG
Results:
N/A
+2 Moderate
pitting
+2 moderate
pitting
+2 moderate pitting
SUBJECTIVE/OBJECTIVE ASSESSMENT
NURSING PROCESS: PART 1
Discharge /Home care [needs after hospitalization]







‘
Discuss all medications including their purpose and schedule, adverse effects, and potential long-term effects.
Discuss importance of complying with all prescribed medications. And how to obtain them for free or a low
cost.
Discuss importance of follow up with provider and when to call provider.
Anticipated lifestyle changes: smoking and drug cessation programs
Housing/shelter: since patient arrived homeless. A list of shelters and a social worker to assist with temporary
housing. (A great resource for this patient could have been Salvation Army’s Harbor Light program. They
specialize in providing temporary housing and rehabilitation programs.)
Transportation assistance to and from follow ups.
Nutrition: resource on where to obtain nutritional meals as a homeless male.
Teaching needs [data based]:








Language: English
Education level: Unknown
Teach pt. how to reduce risk of infection and signs of infection to report.
Teach pt. all medications including their purpose and schedule, adverse effects, and potential long-term
effects.
Teach pt. the importance of compliance to prescribed medication routine.
Discuss proper nutrition and regular exercise.
Discuss knowledge of conditions.
Discuss medication administration and compliance.
Readiness to learn [describe behavior that reflects readiness or ability to learn]:
Due to the patient’s unconscious state, I was unable to assess his readiness to learn. However, it was noted the
patient was a repeat admission for polysubstance abuse.
RNSG 2361
Name
Med/Surg II
Report of Laboratory Test(s) /Diagnostic Procedure
Client’s Values
Significance to patient’s plan of care
The BMP gives your healthcare practitioner important
information about the status of your body's metabolism
(hence the name metabolic panel). The BMP provides
information on your blood sugar (glucose) level, the
balance of electrolytes and fluids, and the health of your
kidneys. Due to the patients DX of polysubstance
overdose and cirrhosis the patient’s liver and kidneys are
being monitored closely.
134-145 mmol/L
152 mmol/L
149 mmol/L
147 mmol/L
Abnormal sodium levels may indicate a kidney problem
or other disorder. In the case of the patient, you can see
his sodium improving despite still being outside normal
limits.
Potassium
3.5-5.1 mmol/L
4.4 mmol/L
4.3 mmol/L
4.4 mmol/L
11/5 2200
11/6 0400
11/6 1000
Chloride
96-106 mEq/L
126 mEq/L
123 mEq/L
121 mEq/L
Too much or too little potassium may indicate a serious
medical problem. In the case of the patient his potassium
was normal. With the patient receiving Lactulose enemas
this is an important value to monitor.
High levels of chloride may be a sign of: Dehydration.
Kidney disease. Metabolic acidosis, a condition in which
you have too much acid in your blood. Once again, the
patients kidneys were being monitored closely for failure.
11/5 2200
11/6 0400
11/6 1000
CO2
23-29 mEq/L
23 mEq/L
24 mEq/L
24 mEq/L
Changes in your CO2 level may suggest that you are
losing or retaining fluid. This may cause an imbalance in
your body's electrolytes. CO2 levels in the blood are
affected by kidney and lung function.
11/5 2200
11/6 0400
11/6 1000
Creatinine
0.5-1.40 mg/dL
0.9 mg/dL
0.8 mg/L
0.9 mg/L
Creatinine is a waste product that is filtered out of your
blood by your kidneys. If you have a high creatinine level
in your blood it is a sign that something is wrong with
your kidneys. Once again, the patient’s liver and kidneys
were being monitored closely due to his diagnosis of
cirrhosis and encephalopathy.
11/5 2200
11/6 0400
11/6 1000
BUN
7-22 mg/dL
35.3 mg/dL
30.9 mg/dL
31.3 mg/dL
Urea nitrogen is a waste product that your kidneys
remove from your blood. Higher than normal BUN levels
may be a sign that your kidneys aren't working well.
Once again, the patient’s liver and kidneys were being
monitored closely due to his diagnosis of cirrhosis and
encephalopathy.
11/5 2200
11/6 0400
11/6 1000
Glucose
<140
113
138
120
Glucose, a type of sugar used by the body for energy.
High glucose levels may point to diabetes. The patient
has a family history of diabetes and was receiving many
fluids like lactated ringers which needed his BS to be
monitored.
11/5 2200
11/6 0400
11/6 1000
Calcium
8.5-10.5 mg/dL
7.1 mg/dL
6.8 mg/dL
6.6 mg/dL
11/5 2200
11/6 0400
11/6 1000
Lactic Acid
>2 mmol/L
1.3 mmol/L
1.1 mmol/L
1.3 mmol/L
A calcium blood test measures the amount of calcium in
your blood. If there is too much or too little calcium in
the blood, it may be a sign of a wide range of medical
conditions, such as bone disease, thyroid disease,
parathyroid disorders, kidney disease, and other
conditions
A higher-than-normal lactic acid level in your blood can
also be a sign of problems with your metabolism. And
your body might need more oxygen than normal because
you have one of the following conditions: Liver disease.
Date
BMP
Name of test
11/5 2200
11/6 0400
11/6 1000
Sodium
11/5 2200
11/6 0400
11/6 1000
Revised Fall 2019
Normal values
Kidney disease. In the case of the patient his liver and
kidneys were being monitored due to his cirrhosis dx.
Blood Gas
Venous
A venous blood gas (VBG) is an alternative method of
estimating systemic carbon dioxide and pH that does not
require arterial blood sampling. The patient is on pressors
on and off. In addition to a mechanical vent so his blood
gases are being monitored closely.
Temperature of the blood.
11/5 2200
11/6 0400
11/6 1000
Temp
36.1 – 37.2 C
37 C
37 C
37 C
11/5 2200
11/6 0400
11/6 1000
Ph, Venous
7.35 -7.45
7.41
7.33
7.31
11/5 2200
11/6 0400
11/6 1000
PCO2,
Venous
35 – 45 mmhg
28.3 mmhg
42.9 mmhg
46.5 mmhg
11/5 2200
11/6 0400
11/6 1000
Base excess,
Venous
-2 - +2 mEq/L
-6
-3
-2.7
11/5 2200
11/6 0400
11/6 1000
P02, venous
75 – 100 mmHg
89.4 mmHg
52.5 mmHg
40 mmHg
11/5 2200
11/6 0400
11/6 1000
HCO3,
Venous
22 -28
17.8
22
22.6
11/5 2200
11/6 0400
11/6 1000
%sat, venous
94 - 100
96.2
77.0
63.3
Total Protein
6 – 8.3 g/dL
4.7 g/dL
5.1 g/dL
3.9 g/dL
Liver
Profile
11/5 2200
11/6 0400
11/6 1000
18
Revised Fall 2019
The first value a nurse should look at is the pH to
determine if the patient is in the normal range, above, or
below. If a patient's pH > 7.45, the patient is in alkalosis.
If the pH < 7.35, then the patient is acidosis. Remember,
the lower the pH number, the higher the acid level in the
body.
The partial pressure of carbon dioxide (PCO2) is the
measure of carbon dioxide within arterial or venous
blood. It often serves as a marker of sufficient alveolar
ventilation within the lungs.
It is defined as the amount of acid required to restore a
liter of blood to its normal pH at a PaCO2 of 40 mmHg.
The base excess increases in metabolic alkalosis and
decreases (or becomes more negative) in metabolic
acidosis
PO2 (partial pressure of oxygen) reflects the amount of
oxygen gas dissolved in the blood. It primarily measures
the effectiveness of the lungs in pulling oxygen into the
blood stream from the atmosphere. Elevated pO2 levels
are associated with: Increased oxygen levels in the
inhaled air.
HCO3 = calculated concentration of bicarbonate in
arterial blood. Base excess/deficit = calculated relative
excess or deficit of base in arterial blood. SaO2 =
calculated arterial oxygen saturation unless a co-oximetry
is obtained, in which case it is measured.
Venous oxygen saturation (SvO2) is a measure of the
oxygen content of the blood returning to the right side of
the heart after perfusing the entire body. When the
oxygen supply is insufficient to meet the metabolic
demands of the tissues, an abnormal SvO2 ensues and
reflects an inadequacy in the systemic oxygenation.
Liver function tests can be used to: Screen for liver
infections, such as hepatitis. Monitor the progression of a
disease, such as viral or alcoholic hepatitis, and determine
how well a treatment is working. Measure the severity of
a disease, particularly scarring of the liver (cirrhosis). The
patient has a preexisting diagnosis of cirrhosis with
ammonia levels currently affecting his status. It was
believed that the patient was possibly unresponsive due to
his fluctuating ammonia levels so his liver profile was
being monitored closely.
If your total protein level is low, you may have a liver or
kidney problem, or it may be that protein isn't being
digested or absorbed properly. A high total protein level
could indicate dehydration or a certain type of cancer,
such as multiple myeloma, that causes protein to
accumulate abnormally. This is consistent with the
patients liver and kidney problems ongoing.
11/5 2200
11/6 0400
11/6 1000
Bilirubin
less than 0.3
mg/dL
1.8 mg/dL
1.6 mg/dL
1.4mg/dL
11/5 2200
11/6 0400
11/6 1000
Alkaline
Phosphatase
44-147 IU/L
81 IU/L
91 IU/L
67 IU/L
11/5 2200
11/6 0400
11/6 1000
AST
8 to 48 U/L
56 U/L
54 U/L
42 U/L
11/5 2200
11/6 0400
11/6 1000
Direct Bili
0 - 0.3 mg/dL
1.0 mg/dL
0.9 mg/dL
0.8 mg/dL
11/5 2200
11/6 0400
11/6 1000
ALT
7 – 55 u/L
39 u/L
39 u/L
28 u/L
11/5 2200
11/6 0400
11/6 1000
Albumin
3.5 -5.5 g/dL
2.1 g/dL
2.2 g/dL
1.7 g/dL
11/5 2200
11/6 0400
11/6 1000
WBC
4.5 – 11.0 x
10^9/L
15.2 x 10^9/L
13.8 x 10^9/L
10.0 x 10^9/L
11/5 2200
11/6 0400
11/6 1000
RBC
4.0 – 5.9
2.40
2.53
2.10
CBC
19
Revised Fall 2019
Bilirubin passes through the liver and is eventually
excreted out of the body. Higher than usual levels of
bilirubin may indicate different types of liver or bile duct
problems. Sometimes, higher bilirubin levels may be
caused by an increased rate of destruction of red blood
cells. This lab result is consistent with the patients
lowered RBCs later in the labs.
An alkaline phosphatase (ALP) test measures the amount
of ALP in your blood. Although ALP exists throughout
your body, the two main sources of ALP in your blood
are your liver and bones. High levels of ALP may
indicate liver disease or certain bone disorders, but an
ALP test alone cannot diagnose a condition
High levels of AST in the blood may be a sign of
hepatitis, cirrhosis, mononucleosis, or other liver
diseases. High AST levels may also be a sign of heart
problems or pancreatitis. If your results are not in the
normal range, it doesn't always mean that you have a
medical condition that needs treatment.
Normal results of the blood test range from 0 to 0.3
mg/dL in adults. If your results on the blood test are
higher, bilirubin may also show up in your urine.
Bilirubin is not present in the urine of normal, healthy
people. Results that are higher may mean that you have a
liver problem, hepatitis, or gallstones.
An ALT test measures the amount of ALT in the blood.
When liver cells are damaged, they release ALT into the
bloodstream. High levels of ALT in your blood may be a
sign of a liver injury or disease. Some types of liver
disease cause high ALT levels before you have symptoms
of the disease. Pertinent to the drug pantoprazole.
An albumin blood test measures the amount of albumin
in your blood. Low albumin levels can be a sign of liver
or kidney disease or another medical condition. High
levels may be a sign of dehydration. Albumin is a protein
made by your liver.
A complete blood count (CBC) is a blood test used to
evaluate your overall health and detect a wide range of
disorders, including anemia, infection, and leukemia. A
complete blood count test measures several components
and features of your blood, including red blood cells,
which carry oxygen. The initial admitting diagnosis of the
patient was sepsis for the monitoring of the patients CBC
would be pretty standard to ensure the sepsis is being
treated effectively. In this case you can very obviously
see the WBC decreasing.
Leukocytosis, or high white blood cell count, can indicate
a range of conditions, including infections, inflammation,
injury and immune system disorders. A complete blood
count (CBC) is usually performed to check for
leukocytosis. Treating the underlying condition usually
reduces your white blood cell count.
The RBC count is almost always part of a complete blood
count (CBC) test. The test can help diagnose different
kinds of anemia (low number of RBCs) and other
conditions affecting red blood cells. This is consistent
with the liver profile.
11/5 2200
11/6 0400
11/6 1000
Hemoglobin
13.2 – 16.6 g/dL
7.5 g/dL
7.8 g/dL
6.5 g/dL
11/5 2200
11/6 0400
11/6 1000
Hemocrit
41 - 50
23.8
26.2
22.4
11/5 2200
11/6 0400
11/6 1000
MCV
80-100 fL
99.2 fL
103.6 fL
106.7 fL
11/5 2200
11/6 0400
11/6 1000
MCH
27-33 pg
99.2 pg
30.6 pg
31.0 pg
11/5 2200
11/6 0400
11/6 1000
MCHC
30 +/- 2 g/dL
31.3 g/dL
30.8 g/dL
31.0 g/dL
11/5 2200
11/6 0400
11/6 1000
RDW
12 -15 %
62
64.7
67.9
11/5 2200
11/6 0400
11/6 1000
Platelet
165 - 415
88
103
73
11/5 2200
11/6 0400
11/6 1000
Mean
platelet
volume
7-9 fL
88
103
73
The results of your red blood cell count, hemoglobin and
hematocrit are related because they each measure aspects
of your red blood cells. If the measures in these three
areas are lower than normal, you have anemia. Anemia
causes fatigue and weakness.
A hematocrit test is part of a complete blood count
(CBC). Measuring the proportion of red blood cells in
your blood can help your doctor make a diagnosis or
monitor your response to a treatment. A lower-thannormal hematocrit can indicate: An insufficient supply of
healthy red blood cells (anemia)
An MCV blood test is often part of a complete blood
count (CBC). A CBC is a common blood test that
measures many parts of your blood, including red blood
cells. It is used to check your general health. An MCV
test may also be used with other tests to help diagnose or
monitor certain blood disorders, including anemia.
The mean corpuscular hemoglobin (MCH) measurement
is part of a complete blood count (CBC) test. The MCH
represents the average amount of hemoglobin in a cell.
Hemoglobin is a protein in red blood cells that carries
oxygen and carbon dioxide. A low MCH can indicate
conditions like anemia and thalassemia.
Mean corpuscular hemoglobin concentration analyzes the
average amount of hemoglobin as it relates to the volume
of a red blood cell. MCHC is a useful measurement when
assessing how well your red blood cells are carrying
oxygen.
he RDW blood test is often part of a complete blood
count (CBC), a test that measures many different parts of
your blood, including red cells. The RDW test is
commonly used to help diagnose anemia, a condition in
which your red blood cells can't carry enough oxygen to
the rest of your body.
A platelet count is a quick, common test that counts the
number of platelets in your blood. Platelets are cells that
help your blood clot. A low platelet count might be a sign
of certain cancers or infections. A high platelet count can
put you at risk for harmful blood clots or stroke.
An MPV blood test measures the average size of your
platelets, the blood cells that help your blood clot. When
considered alongside other test results on a complete
blood count (CBC), an MPV test can help your healthcare
provider diagnose blood disorders and other conditions.
Reference:
Lab Tests Online. (n.d.). Retrieved October 7, 2019, from https://labtestsonline.org/.
Fischbach, F. T., & Fischbach, M. A. (2016). Nurses quick reference to common laboratory & diagnostic tests (6th ed.). Philadelphia:
Wolters Kluwer Health/Lippincott Williams & Wilkins.
20
Revised Fall 2019
Medication Sheet
Medication/Dose/Route/Time
Norepinephrine 4 mg in 0.9% NaCl 250ml (o.016 mg/mL) IV drip premix
Classification:
Alpha, beta agonist. CLINICAL: Vasopressor
Therapeutic Use:
Severe hypotension, treatment of shock persisting after fluid volume replacement.
Nursing Considerations:
BASELINE ASSESSMENT
Assess EKG, B/P continuously (be alert to precipitous B/P drop). Be alert to pt complaint of headache.
INTERVENTION/EVALUATION
Monitor IV flow rate diligently. Assess for extravasation characterized by blanching of skin over vein,
coolness (results from local vasoconstriction); color, temperature of IV site extremity (pallor, cyanosis,
mottling). Assess nailbed capillary refill. Monitor I&O; measure output hourly, report urine output less than
30 mL/hr. Once B/P parameter has been reached, IV infusion should not be restarted unless systolic B/P falls
below 90 mm Hg.
Kizior, Robert J., and Barbara B. Hodgson. Saunders Drug Handbook for Health Professionals 2000. W.B.
Saunders Co., 2000.
Side Effects/Incompatibilities/Toxic Reactions:
INTERACTIONS:
MAOIs (e.g., phenelzine, selegiline), antidepressants (tricyclic)
may prolong hypertension. HERBAL: None significant. FOOD: None known. LAB VALUES: None
significant.
SIDE EFFECTS:
Occasional (5%–3%): Anxiety, bradycardia, palpitations. Rare (2%–1%): Nausea, anginal pain, shortness of
breath, fever.
ADVERSE EFFECTS/ TOXIC REACTIONS:
Extravasation may produce tissue necrosis, sloughing. Overdose manifested as severe hypertension with
violent headache (may be first clinical sign of overdose), arrhythmias, photophobia, retrosternal or
pharyngeal pain, pallor, diaphoresis, vomiting. Prolonged therapy may result in plasma volume depletion.
Hypotension may recur if plasma volume is not maintained.
Contraindications:
Contraindications:
Hypersensitivity to norepinephrine. Hypotension related to hypovolemia (except in emergency to maintain
coronary/cerebral perfusion until volume replaced), mesenteric/peripheral vascular thrombosis (unless it is
lifesaving procedure). Cautions: Concurrent use of MAOIs
21
Revised Fall 2019
Pertinent Labs:

None
Safe Dose Range:
IV
Reconstitution Add 4 mL (4 mg) to 250 mL D5W (16 mcg/mL). Maximum concentration: 32 mL (32 mg) to
250 mL (128 mcg/mL). Rate of Administration. Closely monitor IV infusion flow rate (use infusion pump).
Monitor B/P q2min during IV infusion until desired therapeutic response is achieved, then q5min during
remaining IV infusion. Never leave pt unattended. Maintain B/P at 90–100 mm Hg in previously
normotensive pts, and 30–40 mm Hg below preexisting B/P in previously hypertensive pts. Reduce IV
infusion gradually. Avoid abrupt withdrawal. If using peripherally inserted catheter, it is imperative to check
the IV site frequently for free flow and infused vein for blanching, hardness to vein, coldness, pallor to
extremity. If extravasation occurs, area should be infiltrated with 10–15 mL sterile saline containing 5–10 mg
phentolamine (does not alter pressor effects of norepinephrine).
Is this a safe dose to be administered to the patient?
Drug Reference:
X□ Yes
□ No
Kizior, Robert J., and Barbara B. Hodgson. Saunders Drug Handbook for Health Professionals 2000. W.B. Saunders
Co., 2000. Pg 823-825
22
Revised Fall 2019
Medication Sheet
Medication/Dose/Route/Time
Lactulose solution for enema 300 mL menopenem 2000mg in sodium chloride 0.9% 100mL IVPB
Classification:
Lactose derivative. CLINICAL: Hyperosmotic laxative, ammonia detoxicant.
Therapeutic Use:
Prevention, treatment of portal-systemic encephalopathy (including hepatic precoma, coma); treatment of constipation.
Nursing Considerations:
BASELINE ASSESSMENT
Question usual stool pattern, frequency, characteristics. Conduct neurological exam in pts with elevated serum
ammonia levels, symptoms of encephalopathy. Assess hydration status.
INTERVENTION/EVALUATION
Encourage adequate fluid intake. Assess bowel sounds for peristalsis. Monitor daily pattern of bowel activity, stool
consistency, record time of evacuation. Assess for abdominal disturbances. Monitor serum electrolytes in pts with
prolonged, frequent, excessive use of medication. Monitor encephalopathic pts for symptom improvement (alertness,
orientation, ability to follow commands).
PATIENT/FAMILY TEACHING
• Evacuation occurs in 24–48 hours of initial dose.
• Institute measures to promote defecation: increase fluid intake, exercise, high-fiber diet.
• Drink plenty of fluids.
• If therapy was started to treat high ammonia levels, notify physician if worsening of confusion, lethargy, weakness
occurs.
Side Effects/Incompatibilities/Toxic Reactions:
INTERACTIONS:
DRUG: None significant. HERBAL: None significant. FOOD: None known. LAB VALUES: May decrease serum
potassium (GI loss).
SIDE EFFECTS:
Occasional: Abdominal cramping, flatulence, increased thirst, abdominal discomfort.
Rare: Nausea, vomiting.
ADVERSE EFFECTS/TOXIC REACTIONS:
Severe diarrhea may cause dehydration, electrolyte imbalance. Long-term use may result in laxative dependence,
chronic constipation, loss of normal bowel function.
Contraindications:
Contraindications:
Hypersensitivity to lactulose. Pts requiring a low-galactose diet. Cautions: Diabetes, hepatic impairment, dehydration.
Pertinent Labs:
Serum potassium in a BUN.
Safe Dose Range :
Rectal
23
Revised Fall 2019
Lubricate anus with petroleum jelly before enema insertion. Insert carefully (prevents damage to rectal wall) with
nozzle toward navel. Squeeze container until entire dose expelled. Instruct pt to retain 30–60 min in divided doses.
Maximum: 60 mL/day (40 g/day). Rectal Administration (as Retention Enema) 200 g (300 mL) diluted with 700 mL
water or NaCl via rectal balloon catheter. Retain 30–60 min q4–6h. (Transition to oral prior to stopping rectal
administration.)
X□ Yes
Is this a safe dose to be administered to the patient?
Drug Reference:
□ No
Kizior, R. J. and Hodgson, B. B. (2020) Saunders Nursing Drug Handbook, St. Louis, Missouri. Elselvier Page 635637
24
Revised Fall 2019
Medication Sheet
Medication/Dose/Route/Time
Pantoprazole injection 40mg
Classification:
Benzimidazole. CLINICAL: Proton pump inhibitor.
Therapeutic Use:
PO: Treatment, maintenance of healing of erosive esophagitis associated with gastroesophageal
reflux disease (GERD). Reduction of relapse rate of heartburn symptoms in GERD. Treatment of hypersecretory
conditions including Zollinger-Ellison syndrome.
IV: Short-term treatment of erosive esophagitis associated with GERD, treatment of hypersecretory conditions.
OFF-LABEL: Peptic ulcer disease, active ulcer bleeding (injection), adjunct in treatment of H. pylori, stress ulcer
prophylaxis in critically ill pts.
Nursing Considerations:
BASELINE ASSESSMENT
Question history of GI disease, ulcers, GERD.
INTERVENTION/EVALUATION
Evaluate for therapeutic response (relief of GI symptoms). Question if GI discomfort, nausea occur. Monitor for
abdominal pain, diarrhea (with or without fever).
PATIENT/FAMILY TEACHING
• Report abdominal pain, diarrhea (with or without fever) that does not resolve; may indicate colon infection.
• Avoid alcohol.
• Swallow tablets whole; do not chew, crush, dissolve, or divide.
• Best if given before breakfast. May give without regard to food.
Side Effects/Incompatibilities/Toxic Reactions:
SIDE EFFECTS:
Rare (less than 2%): Diarrhea, headache, dizziness, pruritus, rash.
ADVERSE EFFECTS/TOXIC REACTIONS:
Hyperglycemia occurs rarely. May increase risk of C.difficile–associated diarrhea.
INTERACTIONS:
May increase effects of warfarin. May decrease effects of atazanavir, captopril, clopidogrel, dasatinib,
nelfinavir. HERBAL: Ginger, goldenseal may decrease effect. FOOD: None known. LAB VALUES: May increase
serum creatinine, cholesterol, uric acid, glucose, lipoprotein, ALT.
Contraindications:
Contraindications: Hypersensitivity to pantoprazole, other proton pump inhibitors (e.g., omeprazole). Cautions: May
increase risk of fractures, GI infections
Pertinent Labs:
LAB VALUES: May increase serum creatinine, cholesterol, uric acid, glucose, lipoprotein, ALT.
Safe Dose Range:
IV (route listed due to this being the dose given in the hospital)
25
Revised Fall 2019
Reconstitution Mix 40-mg vial with 10 mL 0.9% NaCl injection. May be further diluted with 100 mL D5W, 0.9%
NaCl. Rate of Administration Infuse 10 mL solution over at least 2 min. Infuse 100 mL solution over at least 15 min.
Flush IV line after administration. Storage Store undiluted vials at room temperature. Once diluted with 10 mL 0.9%
NaCl, stable for 96 hrs at room temperature; when further diluted with 100 mL, stable for 96 hrs at room temperature.
Is this a safe dose to be administered to the patient?
Drug Reference:
□X Yes
□ No
Kizior, R. J. and Hodgson, B. B. (2020) Saunders Nursing Drug Handbook, St. Louis, Missouri. Elselvier Page 873875
26
Revised Fall 2019
List all with a minimum of four (5) appropriate nursing diagnoses for this patient.
1. Ineffective airway clearance as related to the patients overdose on poly substances resulting in a lung
injury as evidence by the patient’s shortness of breath and need for mechanical ventilation.
2. Excess fluid volume as related to the patient malnutrition and excess sodium as evidenced by the
patient’s edema and altered mental status.
3. Impaired thermoregulation as related to the patient’s inability to regulate his core body temperature
as evidenced by the patient’s low body temperature
4. Ineffective coping related to coping skills as evidence by the patient’s poly substance abuse.
5. Impaired skin integrity as related to the patient’s altered circulation as evidence by the presence of
edema and ascites.
Nursing
Diagnosis #1
Excess fluid volume as related to the patient malnutrition and excess sodium as evidenced
by the patient’s edema and altered mental status.
Goal: Partially Demonstrate stabilized fluid volume, with balanced I&O, stable weight, vital signs within
patient’s normal range, and absence of edema.
Met
Outcome Criteria: (The goal has been met if the client…)
Throughout the shift the patient will demonstrate balanced intake and output.
MET
Not met Throughout the shift the patient’s edema will decrease.
MET
Thought out the shift the patients’ vital signs will remain within normal limits.
Priority Nursing Interventions
Measure I&O, weigh daily, and note
gain of more than 0.5 kg/day. (vera,
2022)
Monitor BP (and CVP if available).
Note JVD and abdominal vein
distension. (vera, 2022
Auscultate lungs, noting diminished
breath sounds and developing
adventitious sounds. (vera, 2022)
Measure abdominal girth. (vera,
2022)
Scientific Rationale for Every
Intervention
To assess circulating volume status,
developing or resolution of fluid
shifts, and response to therapeutic
regimen. Positive balance/weight gain
often reflects continuing fluid
retention. Note: Decreased circulating
volume (fluid shifts) may directly
affect renal function and urine output,
resulting in hepatorenal syndrome.
(vera, 2022)
BP elevations are usually associated
with fluid volume excess but may not
occur because of fluid shifts out of the
vascular space. Distension of external
jugular and abdominal veins is
associated with vascular congestion.
(vera, 2022)
Increasing pulmonary congestion may
result in consolidation, impaired gas
exchange, and complications. (vera,
2022)
Reflects accumulation of fluid
(ascites) resulting from loss of plasma
proteins/fluid into peritoneal
space. Note: Excessive fluid
accumulation can reduce circulating
volume, creating a deficit (signs of
dehydration). (vera, 2022)
27
Revised Fall 2019
Evaluation of each Nursing
Intervention
Patients I & O and weight were within
the appropriate range throughout shift.
Blood pressure was on the
hypotensive side throughout shift not
indicating BP elevations associated
with fluid volume gains.
Left lower lungs had crackle present
this was noted as an improvement
from admission status.
The patients abdominal girth did not
increase during shift but was
distended due to his ascites and
cirrhosis.
Care Plan to be continued
Revisions to plan of care
Reference: (APA Format with
pages numbers-Reference within
last 5 years)
yes__X____ no_______
Matt Vera, BSN. “8 Liver Cirrhosis (Hepatic Cirrhosis) Nursing Care
Plans.” Nurseslabs, 18 Mar. 2022, https://nurseslabs.com/8-livercirrhosis-nursing-care-plans/2/.
28
Revised Fall 2019
Impaired skin integrity as related to the patient’s altered circulation as evidence by the
Nursing
Diagnosis #2
presence of edema and ascites
The patient will maintain skin integrity throughout his hospital stay.
Goal: MET
Outcome Criteria: (The goal has been met if the client…)
Patient will not gain any new pressure injuries throughout shift.
MET
Patient will not gain any not gain any areas of redness throughout shift
MET
MET
Patient will rotate frequently throughout shift and comply with preventative measures.
Priority Nursing Interventions
Scientific Rationale For Every
Evaluation of each Nursing
Intervention
Intervention
Inspect pressure points and skin
Edematous tissues are more prone to
Pressure points presented no new
surfaces closely and routinely.
breakdown and to the formation of
redness throughout the shift. Pillows
Gently massage bony prominences or decubitus. Ascites may stretch the
place under boney prominences.
areas of continued stress. Use of
skin to the point of tearing in severe
emollient lotions and limiting use of
cirrhosis. (vera, 2022)
soap for bathing may help. (vera,
2022)
Recommend elevating lower
Enhances venous return and reduces
Extremities were successfully
extremities. (vera, 2022)
edema formation in extremities. (vera, elevated throughout shift.
2022)
Keep linens dry and free of wrinkles. Moisture aggravates pruritus and
Linens and multiple chucks were
(Vera, 2022)
increases risk of skin breakdown.
change throughout shift and carefully
(Vera, 2022)
check for wrinkles.
Use alternating pressure mattress or
Reduces dermal pressure, increases
Patient was in a air mattress due to the
air mattress overlay. (vera, 2022)
circulation, and diminishes risk of
MDs order to not turn the patient until
tissue ischemia. (Vera, 2022)
he stabilized a little more.
Assist patient with reposition on a
Repositioning reduces pressure on
Patient was approved to resume
regular schedule. Assist with active
edematous tissues to improve
repositioning q 2 hours by the end of
and passive ROM exercises as
circulation. Exercises enhance
the shift. Passive ROM was practice
appropriate. (vera, 2022)
circulation and improve and/or
on his extremities in the mean time.
maintain joint mobility. (vera, 2022)
yes__X____ no_______
Care Plan to be continued
Revisions to plan of care
Reference: (APA Format with
Matt Vera, BSN. “8 Liver Cirrhosis (Hepatic Cirrhosis) Nursing Care
pages numbers-Reference within
Plans.” Nurseslabs, 18 Mar. 2022, https://nurseslabs.com/8-liverlast 5 years)
cirrhosis-nursing-care-plans/3/.
29
Revised Fall 2019
Nursing Diagnosis #3
Ineffective coping related to coping skills as evidence by the patient’s poly substance abuse.
Goal: MET
The client will abstain from alcohol and drug use thought the hospital stay.
Outcome Criteria: (The goal has been met if the client…)
Patient will detox from polysubstances throughout shift.
MET
Patient will refrain from obtaining any substances while in the hospital.
MET
Not yet
Patient will verbalize a plan to consider lifestyle changes prior to discharge.
MET
Priority Nursing Interventions
Identify specific stressors. (Wayne, 2022)
Scientific Rationale For Every Intervention
Evaluation of each Nursing Intervention
Accurate appraisal can facilitate development of
Specific stressors identified from chart,
appropriate coping strategies. Because a patient has homelessness.
an altered health status does not mean the coping
difficulties he or she exhibits are only (if at all)
related to that. Persistent stressors may exhaust the
patient’s ability to maintain effective coping.
(Wayne, 2022)
Observe for causes of ineffective coping such as
Situational factors must be identified to gain an
Observed zero support system from chart and prior
poor self-concept, grief, lack of problem-solving
understanding of the patient’s current situation and
admissions with no family or emergency contacts to
skills, lack of support, or recent change in life
to aid patient with coping effectively. (Wayne,
notify.
situation. (Wayne, 2022)
2022)
Successful adjustment is influenced by previous
Past uses of coping mechanisms includes poly
Analyze past use of coping mechanisms including coping success. patients with a history of
substances.
decision-making and problem-solving. (Wayne,
maladaptive coping may need additional resources.
2022)
Likewise, previously successful coping skills may
be inadequate in the present situation (Wayne,
2022)
Patients may have support in a single setting, such
Resources available to the patient include Ben Taub
Evaluate resources and support systems available
as during hospitalization, yet lack sufficient support social worker / case manager and outside settings
to the patient. (Wayne, 2022
in the home setting. (Wayne, 2022)
like TSA Harbor Light.
Assess for suicidal tendencies. (Wayne, 2022)
health care immediately if indicated.
Identify an Unable to assess at this time due to his unconscious
emergency plan should the patient become suicidal. state / altered mental status.
A suicidal patient is not safe in the home
environment unless supported by professional help.
(Wayne, 2022)
yes__X____ no_______
Care Plan to be continued
Revisions to plan of care
Reference: (APA Format with pages numbersGil Wayne, BSN. “Ineffective Coping – Nursing Diagnosis &amp; Care Plan.” Nurseslabs, 19 Mar. 2022,
Reference within last 5 years)
https://nurseslabs.com/ineffective-coping/.
Revised Fall 2019
Nursing Diagnosis #4
Ineffective airway clearance as related to the patients overdose on poly substances resulting in a lung injury as evidence by
the patient’s shortness of breath and need for mechanical ventilation.
Goal:
The patient will warm to a core body temperature of 37 degrees and maintain this temperature.
met
Outcome Criteria: (The goal has been met if the client…)
Throughout the shift the patient will not shiver
MET
Throughout shift the Pt. skin temperature will remain warm to touch and with pink undertones.
MET
Thought the shift the pt. will gradually need less rewarming mechanisms.
MET
Priority Nursing Interventions
Scientific Rationale For Every Intervention
Evaluation of each Nursing Intervention
Assess airway for patency. (Wayne, 2022)
Maintaining patent airway is always the first
The airway was patient with the use of a
priority, especially in cases like trauma, acute
mechanical vent.
neurological decompensation, or cardiac arrest.
(Wayne, 2022)
Auscultate lungs for presence of normal or
Abnormal breath sounds can be heard as fluid and
Left lower lungs had crackles present.
adventitious breath sounds. (Wayne, 2022)
mucus accumulate. This may indicate ineffective
airway clearance. (Wayne, 2022)
Assess respirations. Note quality, rate, pattern,
A change in the usual respiration may mean
Respiration rate was even and unlabored with the
depth, flaring of nostrils, dyspnea on exertion,
respiratory compromise. An increase in respiratory
assistance of the mechanical vent.
evidence of splinting, use of accessory muscles,
rate and rhythm may be a compensatory response to
and position for breathing. (Wayne, 2022)
airway obstruction. (Wayne, 2022)
Note for changes in HR, BP, and temperature.
Increased work of breathing can lead to tachycardia Blood pressure remained slightly hypotensive
(Wayne, 2022)
and hypertension. Retained secretions or atelectasis throughout shift.
may be a sign of an existing infection or
inflammatory process manifested by a fever or
increased temperature. (Wayne, 2022)
Note presence of sputum; examine its quality,
Unusual appearance of secretions may be a result of Sputum was thick and accumulated frequently
color, amount, odor, and consistency. (Wayne,
infection, bronchitis, chronic smoking, or other
needing frequent suctioning of the vent. Patient was
2022)
condition. A discolored sputum is a sign of
very uncomfortable during suctions.
infection; an odor may be present. Dehydration may
be present if patient has labored breathing with
thick, tenacious secretions that increase airway
resistance. (Wayne, 2022)
yes__X____ no___ ____
Care Plan to be continued
Revisions to plan of care
Reference: (APA Format with pages numbersGil Wayne, BSN. “Ineffective Airway Clearance – Nursing Diagnosis &amp; Care Plan.” Nurseslabs, 19
Reference within last 5 years)
Mar. 2022, https://nurseslabs.com/ineffective-airway-clearance/.
Taylor, C. Lillis C.; and Lynn, P. (2015) Fundamentals of Nursing 8th Edition St. Louis, Philadelphia, PA.
Wolters Kluwer Page 641, 655, 878,
18
Revised Fall 2019
18
Revised Fall 2019
Medical Record Documentation
This documentation simulates real patient charting. Follow all the rules of legal charting as taught for complete, concise,
and accurate recording of the patient’s physical, psychological, and social findings. Be specific about the care you delivered.
This section should coincide with the planned interventions, nursing activities, and medications given. Use professional
medical terms and language. When recording an intervention, start with the assessment; describe the intervention and the
patient response to the intervention. Use accepted institutional abbreviations. Legally, if it’s not documented, then it wasn’t
done.
Date & time
Narrative Charting
Signature & Title
0730
Received bedside report for all patients.
GR SRN
0745
Pt. received lying in bed unconscious on a mechanical vent. In supine
position. Pt grimaces to painful stimuli and suctioning. Initial assessment
performed. Pinpoint pupils observed that do not react to light. Bed
positioned low. Restraints in place and side rails up x2.
Vital signs taken (BP 96/64 T 93.4F O2 100 RR 18 BS 114)
Extremities checked no signs of discharge, erythema, or edema. Edema and
weeping in arms and legs. Bear hugger warming device applied. Bed
positioned low. Restraints in place and side rails up x2.
Pt. medication administered: Pantoprazole 40mg IV
No side effects or adverse reactions noted. Pt is still unresponsive, bed
positioned low. Restraints in place and side rails x2. No position change per
PHCPs orders.
Arterial line placed by a resident and fellow. Administered Morphine
Sulfate 2mg/ml IV PRN bed positioned low. Side rails x2. Pt is responsive,
A/O, NAD.
Elevated patients’ extremities. Used pillows for arm and knee support.
Inspected skin again. Patient suctioned at this time. Bed in lowest position,
restraints in place and side rails x 2
Patient received an endoscopy by MD with sedation. Endoscopy revealed
the cause on the GI bleed appeared to be healing. Patient resting in bed Bed
in lowest position, restraints in place and side rails x 2.
Patient receive new order for a rectal tube. Rectal tube placed and
suctioning to endotracheal tube completed. Bed positioned low. Restraints
in place and side rails x2. Patient remains unresponsive.
GR SRN
0900
0930
1000
1100
1200
1400
GR SRN
GR SRN
GR SRN
GR SRN
GR SRN
References
Centers for Disease Control and Prevention. (2022, August 9). What is sepsis? Centers for Disease Control and
Prevention. Retrieved November 23, 2022, from https://www.cdc.gov/sepsis/what-is-sepsis.html
Centers for Disease Control and Prevention. (2022, February 23). Polysubstance use facts. Centers for Disease
Control and Prevention. Retrieved November 23, 2022, from
https://www.cdc.gov/stopoverdose/polysubstance-use/index.html
Etiology: What causes addiction? Recovery Research Institute. (2019, June 17). Retrieved November 23, 2022,
from https://www.recoveryanswers.org/addiction-101/etiology-what-causes-addiction/
Gil Wayne, B. S. N. (2022, March 19). Ineffective airway clearance – nursing diagnosis & care plan.
Nurseslabs. Retrieved November 23, 2022, from https://nurseslabs.com/ineffective-airway-clearance/
Gil Wayne, B. S. N. (2022, March 19). Ineffective coping – nursing diagnosis & care plan. Nurseslabs.
Retrieved November 23, 2022, from https://nurseslabs.com/ineffective-coping/
Revised Fall 2019
Head injury. Head Injury | Johns Hopkins Medicine. (2021, August 8). Retrieved November 23, 2022, from
https://www.hopkinsmedicine.org/health/conditions-and-diseases/head-injury
Kizior, R. J., & Hodgson, B. B. (2000). Saunders Drug Handbook for Health Professionals 2000. W.B.
Saunders Co.
Lewis, S. M., Bucher, L., Heitkemper, M. M., Harding, M., Barry, M. A., Lok, J., Tyerman, J., Goldsworthy, S.,
& Lewis, S. M. (2019). Medical-Surgical Nursing in Canada: Assessment and management of clinical
problems. Elsevier.
Matt Vera, B. S. N. (2022, March 18). 8 liver cirrhosis (hepatic cirrhosis) nursing care plans. Nurseslabs.
Retrieved November 23, 2022, from https://nurseslabs.com/8-liver-cirrhosis-nursing-care-plans/2/
Matt Vera, B. S. N. (2022, March 18). 8 liver cirrhosis (hepatic cirrhosis) nursing care plans. Nurseslabs.
Retrieved November 23, 2022, from https://nurseslabs.com/8-liver-cirrhosis-nursing-care-plans/3/
Reed-Guy, L. (2018, September 29). Head injury: Types, causes, and symptoms. Healthline. Retrieved
November 23, 2022, from https://www.healthline.com/health/head-injury#causes
Sepsis. NHS inform. (n.d.). Retrieved November 23, 2022, from https://www.nhsinform.scot/illnesses-andconditions/blood-and-lymph/sepsis
Stearns-Kurosawa, D. J., Osuchowski, M. F., Valentine, C., Kurosawa, S., & Remick, D. G. (2011). The
pathogenesis of sepsis. Annual review of pathology. Retrieved November 23, 2022, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684427/
18
Revised Fall 2019
Medical/Surgical Clinical Rotation
RNSG 2361 Grading Rubric
Student Name___Greta Reece________________ Date of Care_11/5/22____ NCP# ________
On time___ Late______ Grade _______
Criteria
NCP due date:
Unsatisfactory/Unacceptable
Needs Improvement
Satisfactory
Documents are submitted after due
date will have 10 points deducted
per late day.
-
Final documents are submitted by
11:59 pm on due date (1 week
after clinical day)
DATA COLLECTION:
Criteria
History of Present Illness prior to
Hospitalization
ASSESSMENT- 20%
Unsatisfactory/Unacceptable
Needs Improvement
Incomplete
Satisfactory
Complete account of present
illness
0
Past Medical History
1
Incomplete
Complete PMH
0
Family Medical History and Social
History
Incomplete
Admission Timeline
Incomplete, too general or
inaccurate
1
Complete FMH and SH
0
1
Provides admission timeline
related to chief complaint or
admitting diagnosis.
1
0
Criteria
Pathophysiology
Lab Values
Unsatisfactory/Unacceptable
Needs Improvement
Satisfactory
Provides definition directly from
book and fails to include two or
more of the following: risk factors,
clinical manifestations, or
complications of each disease
process without APA reference
0
Provides definition directly from
book but fails to include one of
the following: risk factors,
clinical manifestations and
complications of each disease
process; cited with APA
reference missing
1.5
Provides pathophysiology in own
words at a cellular level and
includes risk factors, clinical
manifestations and complications
of ALL disease processes; cited
with reference
Incomplete. Inaccurate, omitted
data, or too general
Lab data is complete, accurate,
including hospital & patient
value, abnormal values with
rationale.
0
19
Revised Fall 2019
3
2
Diagnostic Studies
Incomplete, inaccurate, omitted
data or too general
Diagnostic studies are accurate,
includes results and an
explanation of abnormal findings
specific to the patient
1
0
Medications
Medication list is incomplete
and/or required considerable
corrections
0
List of medications are accurate
and complete but indications or
side effects or nursing
interventions are too general or
irrelevant for the patient
1
Identifies appropriate learning needs
Criteria
Not realistic or < 2 of satisfactory
items
0
Unsatisfactory/Unacceptable
Incomplete with only 2 of
satisfactory items.
Medication list is accurate,
complete, specific to the patient,
major and common side effects
are identified, along with nursing
implications
2
Support findings ;
Used in formulation of nursing
diagnosis ; Assesses client’s
readiness to learn
2
1
Needs Improvement
Satisfactory
Comprehensive Assessment
-General Survey
Incomplete
Partially complete (inaccurate,
Complete, accurate, without
-HEENT
omitted data, or too general), or
omission, recorded using
-Neurological
lacks appropriate medical
appropriate medical terminology;
-Cardiovascular
terminology, or abnormal
abnormal findings are bolded
-Respiratory
findings are bolded
-Gastrointestinal
-Genitourinary
-Musculoskeletal
-Integumentary
0
4
6
- Endocrine
-Psychological
ANALYSIS/ NURSING DIAGNOSIS: 16%
Criteria
Unsatisfactory/Unacceptable
Needs Improvement
Satisfactory
Appropriate actual or potential
nursing diagnosis
Nursing diagnosis selected reflects
that no effort to interpret
information was applied resulting
in a flawed plan of care; statement
format is incorrect. Less than 3
nursing diagnosis meet the
satisfactory criteria.
0
Nursing diagnosis reflects the
accurate interpretation of the
assessment data; uses NANDA
terminology; incomplete
statement format.
Only 3-4 nursing diagnosis met
the satisfactory criteria.
Five (5) Nursing diagnoses
reflects the accurate interpretation
of the assessment data; proper use
of NANDA terminology;
“Actual” nursing diagnoses use 3
part statement (PES format) and
“At Risk” nursing diagnosis use 2
part statement
14
PES: Problem, Etiology/Related
to…
Support/ As evidence by…
7
Prioritization
Nursing diagnoses are not ranked
according to Maslow’s Hierarchy
of Needs
0
20
Revised Fall 2019
Nursing diagnoses are ranked to
best reflect Maslow’s Hierarchy
of Needs
1
Use of priority nursing diagnoses
Less than top 3 nursing diagnoses
used.
0
Minimum of 3 nursing diagnoses
used.
1
PLANNING: 10%
Criteria
Unsatisfactory/Unacceptable
Goals
Needs Improvement
Not related to nursing diagnosis
Satisfactory
Clearly stated and Related to
nursing diagnosis
0
Outcome Criteria
[SMART]
Three (3) outcomes are written for
the patient but are missing one of
the elements and/or not related to
goal
0
5
Three outcomes are written for
the patient but are missing one of
the elements; and outcomes are
related to the goal.
2.5
Written with all elements
SMART (Specific, Measurable,
Achievable, Realistic and Timed)
for the patient; and related to goal
5
NURSING INTERVENTIONS/ IMPLEMENTATIONS: 20%
Criteria
Unsatisfactory/Unacceptable
Needs Improvement
Five sufficient and appropriate
nursing actions planned or
implemented to meet the patient
goals are listed.
(assessment, independent action,
education, medication,
collaboration, and discharge
planning) are patient-specific
Interventions are incomplete, miss
labeled, or inappropriate to the
patient
Nursing orders of interventions
Does not provide evidence of
specific cognitive, interpersonal or
technical action to be taken nor
relationship to goal
0
Satisfactory
Interventions do not reflect all
areas but are appropriate for the
patient
0
2.5
5
Intervention is missing evidence
of one item of specificity or goal
related
5
Rationale with supportive scientific
documentation
Rationales for each intervention
when included do not explain the
intervention and consequently its
inclusion cannot be justified;
rationales may or may not have
references
0
Client teaching
No teaching implemented or
appropriate teaching done.
Rationales for each intervention
contain inconsistent supportive
data on why the intervention was
selected or lack evidence based
data; rationales may or may not
have references
1
Interventions are specific
cognitive, interpersonal or
technical approaches, and related
to goal
10
Rationales for each intervention
contain supportive data and
reasoning that identifies why the
intervention was selected or
rationales have references as cited
using APA Manual
2
Interventions are appropriate to
the learning needs identified
3
0
21
Revised Fall 2019
Interventions from five (5) areas
that are appropriate for the
patient.
EVALUATION: 34%
Criteria
Unsatisfactory/Unacceptable
Needs Improvement
Satisfactory
Observation of patient responses
Incorrectly documents nonpatient/family actions under
effectiveness of interventions
0
Correctly identifies 100% of the
results of nursing interventions
15
Evaluation of the Outcomes
Evaluation of the outcome is
incomplete, inaccurate, or too
general with no analysis of data.
Outcomes are evaluated as
met/partially met/not met and
includes the analysis of the data
1
0
Evaluation of the Goal
Incorrect
Correct
0
Revision
1
Revision section is left blank.
An appropriate revision is
identified for each unmet patient
goal.
2
0
Medical Record Documentation
Incomplete, lacking patient focus
or not patient centered; lacking
legalities; appears as journaling
Analyzes of nursing
interventions, client responses,
and adaptation to care given
partially complete (inaccurate,
omitted data, or too general)
7.5
15
-2
Sub-totals
Total Score
22
Revised Fall 2019
Comprehensive, patient-oriented,
comprehensive, complete,
concise & accurate, and using
approved institutional
abbreviation
/100