Name: Kenny Diaz
Faculty Name:__________________________ Date:_____________
N101L: Nursing Process Worksheet
Instructions: Each clinical day, the student will develop a nursing process outline for one patient of their
choice. These will be discussed in clinical and in post-conferences with the faculty. Use the AAPIE Nursing
Framework (Assess, Analyze, Plan, Implement, and Evaluate) for your assigned patient to complete the
Patient Profile Database Worksheet and the Nursing Process Worksheet. Upload to CANVAS after the
conference.
DIRECTIONS
What needs to be done:
Receive Handoff Report
Complete Head-to-Toe Assessment
Review patient chart:
o History and Physical
o Progress Notes
o Laboratory and Diagnostic Tests
o Vital Signs
o Medications
IDENTIFICATION DATA
Completed
YES
Yes
If not, why?
Yes
Patient Initials: J.J.
Age: 78
Gender: Female
Allergies: None
Isolation:
Code Status:
o Full Code
o DNR
o Modified:
NA
CHIEF COMPLAINT
Patient brought in for urosepsis
ADMITTING DIAGNOSIS
Urosepsis
HISTORY OF PRESENT ILLNESS (HPI)
J.J. is a 78-year-old female with a past medical history of congestive heart failure and diabetes mellitus. She
was sent to the emergency department from home at 0500 due to urosepsis. She was assessed and then received
an initial dose of Levofloxacin. The patient's vitals are as follows: T 99.4°, P 96, R 24, BP 136/76, O2 Sat 85%.
Blood glucose levels are above normal limits at A1C 11.3%. WBC 13,000/mm3, Hgb 11.3 g/dL, Hct 33%.
ABG showed: pH 7.28, PaO2 88 mm Hg, PaCO2 35 mm Hg, HCO3- 20 mEq/L. Glyburide has been ordered
for administration at 0800. The patient has cloudy urine with very low output. Intravenous fluids were given
along with fluid bolus to treat her hypotension. The patient is agitated and suffering from fatigue from her
prolonged stay in the emergency department. Chest X-Ray shows hypertrophy of the left ventricle of the heart
along with dilations of the hilar and pulmonary vasculature. Albuterol 0.5 % solution will be given via
nebulizer every 6 hours.
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PERTINENT PAST MEDICAL HISTORY (PMH)
Urosepsis
Diabetes
Congestive Heart Failure
Pathophysiology
Instructions: Provide a complete and detailed pathophysiology of the admitting diagnosis. Must include
signs and symptoms, risk factors, and complications. Must relate the pathophysiology section back to the
patient. Use academic, evidence-based references to support each criteria.
Urosepsis is having organisms in the bloodstream that came from a urinary
tract infection (Banasik et al., 2018, pg. 582). When bacteria is detected in the
blood, local inflammation starts due to the body's immune system response.
Immune cells such as neutrophils and macrophages arrive at the site of
infection to destroy the bacteria. Cytokines and chemokines are also released to
assist with the immune response (Banasik et al., 2018, pg. 174). Organ
dysfunction occurs due the widespread inflammation which can impair blood
flow through vasoconstriction, that narrows the blood vessels and reduces
blood flow leading to hypoxia, and the coagulation system becomes activated
and causes microvascular thrombosis that further compromises organ perfusion
(Banasik et al., 2018, pg. 445).
Pathophysiology of
Admitting Diagnosis
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Common findings of urosepsis is organ dysfunction, hypoperfusion,
hypotension, oliguria & alteration in mental status. The following conditions
associated with urosepsis is temperature greater than 100.4°F (38°C), heart rate
greater than 90 beats per minute, respiratory rate greater than 20 breaths per
minute, White blood cell count greater than 12,000 cells/mm3, hyperglycemia,
arterial hypotension, oliguria, creatine increase greater than 0.5 mg/dL &
decreased capillary refill (Banasik et al., 2018, pg. 445).
Signs & Symptoms
Risk Factors
Complications
Urinary Tract Infections
Older age
Weakened immune system (Diabetes)
Septic Shock
Acute Respiratory Distress Syndrome
Acute Kidney Injury
Disseminated Intravascular Coagulation
Multiple Organ Dysfunction Syndrome
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The patient is showing signs of urosepsis with hypoperfusion (02 sat 85%),
oliguria, altered mental state of being alert and oriented x1, respiratory rate at
Describe the relationship 22 breaths per minute, WBC count at 13,000 cells/mm3, hyperglycemic with
between the pathophysiology A1c 11.3% & capillary refill on all extremities being decreased.
and the patient’s current
condition in your own words
(does not need citation)
CURRENT VITALS AND DATA
HR: 96
RR: 24
Pain: 6
Height (cm): 170 cm
Temp: 99.8°F
BP: 136/76
SpO2: 85%
Weight (kg): 71 kg
ANALYSIS OF ASSESSMENT CUES
Instructions: In the space below, enter both subjective & objective data for all body systems gathered during
your client assessment. Identify the top 3 priority body systems containing the assessment cues with cited
explanations in relation to the patient and admitting diagnosis.
Body System
WNL or
Abnormal
Abnormal
Neuro
List of Abnormal
Assessment Cues
Alert & oriented x1
Explanation of Abnormal
Assessment Cues with
evidence-based citations
The patient does not know that
they are in a hospital or why
she is being treated. An altered
mental state is a sign of
urosepsis (Banasik et al., 2018,
pg. 445). The body’s response
to having urosepsis is to release
inflammatory mediators that
cross the blood-brain barrier
and alter neurotransmitter
function, leading to cognitive
impairment (Banasik et al.,
2018, pg. 446).
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Abnormal
Cardio
Respiratory rate: 24
Pale Skin
Capillary refill on upper/lower
extremities is greater than 3
seconds
Skin is cold
Heart sounds are irregular
Peripheral pulses are
diminished
The inflammatory response
along with the activation of the
coagulation cascade causes
microvascular thrombosis and
impaired tissue perfusion. This
results in hypoxia which causes
the body to compensate by
increasing the respiratory rate
to increase oxygen intake. The
impaired perfusion to the tissue
causes the skin to be pale, cold,
and with delayed capillary refill
(Banasik et al., 2018, pg. 445).
Irregular heart sounds are due
to inflammatory mediators
disrupting the electrical
conduction of the heart, this is
because they can alter ion
channels such as for potassium,
which leads to arrhythmias and
irregular heartbeats (Banasik et
al., 2018, pg. 400)
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Abnormal
Breath sounds: Crackles,
The inflammatory response
wheezes
caused by having urosepsis
Irregular breathing, shortness of leads to impaired perfusion to
breath & labored
the lungs due to
vasoconstriction and reduced
blood flow (Banasik et al.,
2018, pg. 445). The systemic
inflammatory response can
increase vascular permeability
in the lungs & lead to fluid
leakage from the blood vessels
into the alveoli, leading to
alveolar collapse (Banasik et
al., 2018, pg. 504).
Abnormal
Liquid, yellow stool
Resp
Diarrhea is a primary sign of
GI tract disorders. When the
body detects bacterial toxin, the
small intestine secretes chloride
ions and water through active
secretion and inhibits
resorption (Banasik et al., 2018,
pg. 723).
GI
.
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Abnormal
Cloudy urine, amber color
Cloudy urine is a good
indicator of an infection being
present, especially with
leukocytes being present in the
urine (Banasik et al., 2018, pg.
576).
Abnormal
Generalized Weakness
The inflammatory response
along with the activation of the
coagulation cascade causes
microvascular thrombosis and
impaired tissue perfusion. This
results in hypoxia which
accelerates fatigue due to cells
not having enough oxygen for
energy (Banasik et al., 2018,
pg. 445).
Abnormal
High morse fall scale score
Generalized weakness
GU
Skin
WNL
Mobility
Safety
Psych-Soc
Pain
WNL
Abnormal
6/10
ANALYSIS OF TOP 3 LABORATORY DATA/DIAGNOSTIC TESTS
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Lab/Diagnostic Test
Chest X-Ray
Date
Reference
Range
08/01/XX
Why is this test necessary in
Result
relation to the patient’s admitting
diagnosis? Use citations.
Hypertrophy of The reduced amount of blood flow
the left
caused by the inflammatory
ventricle of the response disrupts the cardiac blood
heart
flow and results in myocardial
hypertrophy due to increased
metabolic demands overworking
the muscles of the heart (Banasik et
al., 2018, pg. 362).
MEDICATION LIST
Medication
Generic / Trade
Class
- Pharmacological
- Therapeutic
Purpose
(pertinent to
patient)
Glyburide/
Glynase
Sulfonylureas Lower blood
Antidiabetics
sugar
Dose/Route/Time
(Frequency)
Mechanism
of Action
Common
Side Effects
Nursing
Considerations
2.5
mg/PO/Daily
Stimulate the Hypoglycemia Use cautiously
release of
Hyponatremia
for
insulin from the
cardiovascular
pancreas
disease
Fluoroquinolone
Levofloxacin/
Treats urinary
250
Inhibits DNA Phlebitis at IV Reduce dose
Levaaquin Anti-infectives
tract
mg/IV/Every 12 gyrase enzymes
site.
for renal
infections
hr
which stops
impairment
bacterial DNA
synthesis
Digitalis
glycosides
Digoxin/
Increase
0.25
Increases the
Fatigue
Lower dose for
Antiarrhythmics
Lanoxin
cardiac output mg/PO/Daily
force of
Headache
renal
and slow
myocardial
Weakness
impairment
heart rate
contraction &
decreases
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conduction
through the SA
and AV nodes.
Furosemide/
Lasix
loop diuretics
Diuretics
Decrease
blood
pressure
20 mg/IV/Now
Inhibits to Hyperglycemia Increases risk
reabsorption of Hypotension of ototoxicity
sodium &
with renal
increases renal
impairment
excretion
Binds to beta2 Hyperglycemia Use cautiously
adrenergic
Hypokalemia with diabetes
Albuterol/
Airomir
Adrenergic Relax airway
Bronchodilator
smooth
muscle
0.5%
/Nebulizer/
Every 6 hr
Acetaminophen/
Tylenol
antipyretics
nonopioid
analgesics
Reduce pain
& fever
325mg/PO/
Every 4 hr
Inhibits the
Renal failure Severe hepatic
synthesis of
(High dose/
impairment
prostaglandins Chronic use)
which serve as
CNS mediators
of pain and
fever
Lorazepam/
Ativan
Benzodiazepines
analgesic adjuncts
To sedate,
decrease
anxiety &
decrease
seizures
2mg/PO/
Every 6 hr
Depresses the Blurred vision Use cautiously
CNS
Constipation in severe renal
Diarrhea
impairment
receptors &
decreases
intracellular
calcium which
relaxes smooth
muscle airways
PRIORITY HYPOTHESIS/PROBLEM
Using the pertinent abnormal cues, choose 1 priority hypothesis
Bacterial infection as evidence with an elevated white blood cell count & cloudy urine.
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SMART GOAL
Goal must be Specific, Measurable, Attainable, Realistic, and Timestamped.
Start goal statement with, “Patient will... by...”
Within the week, the patient will improve her mobility and walk independently for 10 minutes for three times a
day. Patient will record progress in a journal.
IMPLEMENTATION
For the identified priority hypothesis/problem, provide 4 independent interventions (1 must be a teaching intervention). All
interventions must have a rationale supported with evidence-based citations.
1. Physical Therapy
Rationale:
The therapy sessions will focus on strength and balance activities that will help the patient with her walking
progress. Having the patient do range of motion exercises will help with the recovery of her motor function
(Banasik et al., 2018, pg. 908).
2. Respiratory Therapy
Rationale:
The patient will see a respiratory therapist to do breathing exercises and techniques that improve lung
function to help with the patient’s endurance. By doing exercises that maintain airway patency and promote
alveolar ventilation, the patient will be able to get adequate oxygenation at the cellular level with oxygen
saturation being at least at 90% (Banasik et al., 2018, pg. 470).
3. Antibiotic Therapy
Rationale:
Antibiotics will be used to target the underlying bacterial infection, which is the source of their urosepsis. A
patient that has signs of sepsis should be given broad-spectrum antibiotics (Banasik et al., 2018, pg. 470).
The patient is currently on Levofloxacin.
4. Fluid Replacement Therapy
Rationale:
Giving the patient fluids such as normal saline will restore the circulating volume and improve tissue
perfusion. This will help support overall organ function by normalizing blood pressure, cardiac output, and
perfusion to the blood vessels (Banasik et al., 2018, pg. 443).
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EVALUATION
Select whether your goal was met, partially met, or not met. If goal was met, explain why.
If goal was partially met or not met, must include revisions.
o Goal Met
Why the goal was met: The patient jumped out of bed this morning and
started skipping around the room. She needed no assistance leaving the
building.
o Goal Partially Met
Revision(s):
o Goal Not Met
Revision(s):
NURSING APPLICATION ASSESSMENT
Instructions: Include activities throughout the day performed in relation to the following NCLEX content
categories. See content category below for examples from the NCSBN.
Management of Care
Nursing treatments provided to patient to help disease or medical problem/s
1. Referred patient to a respiratory therapist and a physical therapist.
Safety and Infection Control
Measures done to keep patient and you are safe, to prevent infection and worse condition
2. Used standard precautions and isolation precautions when dealing with the patient. Patient was
assisted and escorted until their strength came back to walk independently.
Basic Care and Comfort
Nursing measures given to patient to keep clean and comfortable
3. Provided oxygen. Provided fluids.
DEFINITIONS OF ABOVE
Management of Care: providing and directing nursing care that enhances the care delivery setting to protect clients and
health care personnel.
Related content includes but is not limited to: Advance Directives. Advocacy, Assignment, Delegation and
Supervision, Case Management, Client Rights, Collaboration with Interdisciplinary Team, Concepts of
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Management, Confidentiality/Information Security, Continuity of Care, Establishing Priorities, Ethical Practice,
Informed Consent, Information Technology, Legal Rights and Responsibilities, Performance Improvement
(Quality Improvement), Referrals
Safety and Infection Control: protecting clients and health care personnel from health and environmental hazards.
Related content includes but is not limited to: Accident/Error /Injury Prevention, Emergency Response Plan,
Ergonomic Principles, Managing Hazardous and Infectious Materials, Home Safety, Reporting of
Incident/Event/Irregular, Occurrence/Variance, Safe Use of Equipment, Security Plan, Standard
Precautions/Transmission- Based Precautions/Surgical Asepsis, Use of Restraints/Safety Devices
Basic Care and Comfort: providing comfort and assistance in the performance of activities of daily living.
Related content includes but is not limited to: Assistive devices, Elimination, Mobility/Immobility, NonPharmacological Comfort Interventions, Nutrition and Oral Hydration, Personal Hygiene, Rest
STUDENT JOURNAL
Personal goals for the day
What clinical objectives did you focus on today?
Experience (specialty areas) and activities of the day
What new skills or procedures did you witness or participate/assist with?
Thoughts about your experience today
How did you meet your goal? Do you have any preconceived notions that changed?
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Your feelings about today
How can you utilize your experience in the future?
References:
Copstead, L. E., & Banasik, J. L. (2018). Pathophysiology (6th edition). Elsevier.
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