CSU, STANISLAUS B.S.N.
CLINICAL PLAN OF CARE
Student:
Vanessa Van Steyn
Date of Care:
1/6/14-1/7/14
Room Number:
428
Patient Data
Admitting Diagnosis
Complaint Chest Pain, STEMI
Age
63
Spiritual Focus
Jehovah’s Witness- NO BLOOD TRANSF.
Culture
Hispanic
Patient Initials
**
Gender
M
Height
167 inches
Weight
78 kg
Admitting Date
1/1/14
Vital Signs
BP taken q15min while on Dobutamine and Nitroglycerin drip. Dobutamine D/C at 2000 on 1/6/14; Nitroglycerin D/C at 2300 1/6/14. All other vital signs to be taken q4h.
T
97.2 97.8 98.0 98.2 85
BP: Time Taken
1430
1445
1500
1515
1530
1545
1600
1615
1630
1645
1700
1715
1730
P
82
R
86
81
16
1/6/14
112/68
99/63
104/65
Walking
99/59
97/60
101/64
98/61
99/59
95/55
109/69
104/64
99/62
20
18
1/7/14
103/63
26
B/P
See Below
BP: Time Taken
1745
1800
1815
1830
1845
1900
1915
1930
1945
2000
2015
2030
2045
94
O2Sat
94
95
98
0
1/6/14
104/64
100/67
100/64
108/65
89/62
95/58
96/55
92/49
97/57
105/62
91/54
102/54
Walking
Pain Scale
0
6
8
1/7/14
99/54
Past Medical History
Type II Diabetes, Hypertension, Hyperlipidemia, Unstable Angina type II, CHF III, Acute Left Vent. Systolic Dysfunction.
Surgical History
Left Knee Surgery (unknown reason)
Diet:
Advance Directives: No
Code Status:
Ambulate in the hallway
Ankle Pumps x 20
Wrist Pumps x 20
NG inserted 1/5/14 with
intermittent suction
D/C 1/6/14
Full
VS Freq:
TEDs/SCDs:
TEDS
Telemetry:
Yes
Foley:
PCA/Epidural:
Clear Liquid (1/5/14)
NPO (1/6/14)
Clear Liquid (1/7/14)
Yes
BP q15m with
Dobutamine and
nitroglycerin drip.
q4h all other
None
Vascular Access:
Activity:
NG/Feeding Tube:
Drains/
Tubes:
Mediastinal Chest tube X
2
Glucose
Monitoring:
AC and qhs
Dressing Changes:
IV
0.9% NS @ 5ml/hr.
Solution:
Pt. is unwilling to receive blood transfusions due to religious beliefs. States he is willing to accept synthetic clotting
factors and albumin. Use pediatric tubes when obtaining blood draws… no CBC or blood levels.
Mediastinal chest site, 4 dressings for staples on left leg (donor site)
Labs to be Drawn:
BMP, Magnesium (AM 1/6 and 1/7)
Scheduled Procedures:
None
Notes on Pathophysiology:
Pt arrives at ER with complaints of chest pain ECG shows STEMICardiac Cath procedure Triple Vessel
Disease (decided nothing much they could do in cath lab, and inserted balloon pump to hold pt. over until emergency
surgery)  Emergency CABG procedure with 4 donor vessels paralytic ileus NPO
Safety Considerations:
IV Site: Triple Lumen Catheter Central Line
Lab and Diagnostic Test Data
Test type
(date)
Chem-7
Na
K
Cl
CO 2
Calcium
Glucose
Magnesium
Kidneys
BUN
Creatinine
GFR
Liver
Total Protein
Albumin
Globulin
Bilirubin Total
AST
ALT
Lipase
Normal
Range
135-145
3.3-5.0
95-110
24-32
8.0-11.0
70-110
1.2-2.0
8-22
0.5-1.3
>60
6.0-9.0
3.8-5.1
2.1-3.7
0.3-1.3
8-42
10-60
10-140
Pt Results
1/5
1/6
1/7
136
4.1
109
24
8.1
87
2.6
133
4.2
105
25
7.9
136
2.5
135
4.0
105
25
7.5
135
2.8
1/5
1/6
1/7
Trends ↑
High
High
15
26
27
High
0.80 1.01 0.91
>60 >60 >60
1/6
1/7
5.8
3.1
2.7
0.9
62
34
44
5.5
2.7
2.8
1.1
38
29
---
Low
Low
High
Rationale
(Specific to pt.)
Patient’s electrolytes are within
normal limits. His glucose level is
slightly high however this could be
due to his type 2 diabetes and stress.
This blood glucose will be managed
with his prescribed insulin and
continue to be monitored throughout
his stay. The magnesium can be
increased due to dehydration, and I
was also thinking it could be raised
due to acute kidney failure due to
decreased blood flow from the STEMI
The BUN level can be raised in
patients experiencing acute STEMI’s
as the kidneys have experienced a
decrease in blood flow.
The creatinine and GFR levels
however indicate that the kidneys are
functioning properly, with no disease
present.
The pt’s liver labs are all within
normal limits besides the AST, protein
and the albumin. Albumin and protein
are probably decreased because this
patient is on an NPO/Clear liquid diet
and therefore is not taking in any
protein. The AST is increased because
when disease or injury affects cells
Nursing implications related to patient
care & teaching
I would expect the physician to continue
to monitor the magnesium level due to it
trending high and him having a history of
alcoholism. I would also expect the nurses
and physicians to monitor the glucose,
often by use of a finger stick, in order to
make sure he does not fall into hyper or
hypoglycemia. The rest of his electrolytes
look great, but because he switches
between NPO and clear liquid diet I would
expect them to monitor electrolytes to see
if they need to add any electrolytes to his
solution to keep his heart beating
normally.
I would expect the doctor to continue to
monitor the BUN levels during the
patient’s hospital stay. Although it is the
only kidney lab that is elevated and is
probably due the STEMI, I believe the
physician would continue to make sure
that the BUN returned back to normal
limits. During this period I would expect
the doctor to use caution when ordering
renal toxic medications such as NSAIDS
and ACE inhibitors.
I would be sure to try to increase the
patient’s diet to a level where the patient
was consuming more protein, thus
increasing albumin level. I would also
expect the staff to continue to monitor the
AST and hope to see that it continues to
remain within defined limits and that no
further damage seems to be occurring.
Test type
(date)
Cardiac
Troponin I
Fibrinogen
Blood
WBC
Hgb
Hct
RBC
Platelets
Coagulation
INR
Normal
Range
0.01-0.06
155-558
Pt Results
0.77
167
Trends ↑
High
1/5/14
4.5-11.0
13-16
37-49
4.5-5.3
130-400
18.2
9.9
29.5
3.22
114
High
Low
Low
Low
Low
1/2/14
2.0-3.0
(for MI)
1.5
Rationale
(Specific to pt.)
throughout the body. In this case, the
AST is measuring cells in the heart,
and skeletal muscle, which both
suffered trauma during the STEMI and
surgery.
Troponin levels above 0.50 are highly
suggestive of acute myocardial
infarction and is considered a medical
emergency. Staff must follow the ASA
and Beta-Blocker protocols with a
troponin level >0.50.
Nursing implications related to patient
care & teaching
Patient needed to be taken to the cardiac
cath lab ASAP. Emergency CABG
surgery was performed.
After, rest and monitoring of vital signs
are extremely important. I would continue
to monitor troponin levels and hopefully
watch them decline back to normal levels.
This patient recently went through
The patient is prescribed ferrous sulfate,
cardiac surgery but received no blood
thiamine, and folic acid. Although these
replacement therefore we expect to see medications will definitely help this
an overall decrease of all blood
patient’s RBC levels increase, he has not
products. This is why we see a
been taking them because he is NPO.
decrease in Hgb, Hct, and RBC. We
When he begins taking them we expect to
see an increase in WBC because the
see an increase in all RBC products. For
body is stressed and undergoing an
now, I would expect this patient to have
inflammatory response to begin to heal signs and symptoms of anemia because of
the wounds created by the surgery.
his low RBC, Hgb, and Hct.
The decrease in platelets can really be Because his WBC is increased I would
only fixed by a transfusion; however
continue to monitor for wound healing,
this platelet level is not an emergency. and signs and symptoms of infection such
as fever, redness, warmth, and drainage at
wound site.
I would also teach the patient to use a soft
bristle tooth brush, avoid using a razor to
shave his face, and be aware of signs of
internal bleeds such as black tarry stool.
Although this patient’s INR and PT
I imagine the patient would continue to
are slightly increased, this is because
receive anticoagulant therapy such as low
he is on an aspirin and Plavix
dose aspirin or Plavix when discharged
Test type
(date)
PT
PTT
Normal
Range
9.5-12.2
25-36
17.2
33
 Severe distal left
main disease.
 Subtotal
occlusion of right
coronary artery
 Total occlusion
of circumflex
artery
“Multi-vessel
Disease”
X-RAY
(cardiac cath)
w/ contrast
EKG
Pt Results
Normal
Sinus
Rhythm
Medication Allergies:
Sinus Rhythm
with acute
elevated ST
segment: STEMI
Trends ↑
High
Rationale
Nursing implications related to patient
(Specific to pt.)
care & teaching
anticoagulation therapy. In order to be home.
sure that this patient will not
I would also teach the patient to use a soft
experience another STEMI, he will
bristle tooth brush, avoid using a razor to
need to continue on anticoagulation
shave his face, and be aware of signs of
therapy.
internal bleeds such as black tarry stool.
The x-ray was used during the cardiac catheterization procedure to find out which
vessels were blocked. It turned out that multiple vessels were blocked and therefore
they were unable to stent any vessels to correct the problem. The doctor then
decided to add a balloon pump into the heart in order to allow the heart to rest while
awaiting the emergency CABG procedure.
The EKG that was done upon entrance to the ER showed that the patient had an
elevated ST segment. This made his situation an emergency, and he was rushed to
the Cardiac Cath lab.
NKDA
Medications
Generic & Trade Name
Drug Classification
Dose/Route
Frequency
(Therapeutic &Pharmacologic)
Pantoprazole
Protonix
Proton Pump Inhibitor
Mupirocin
Bactroban
40mg PO daily
(hold if NPO)
40mg IV
(if NPO; dilute
w/10ml NS over 2
min)
1 tube BID for 5
days- Nasal
Action of drug and
Rationale
(specific to Pt)
Binds to an enzyme in
presence of acidic pH
preventing transport of H
ions further into the
lumen
Lessens acid reflux
Significant Side Effects
Nursing implications related to
patient care & teaching
Hyperglycemia,
hypomagnesaemia,
abdominal pain, headache,
diarrhea, flatulence.
Avoid alcohol, Avoid NSAIDS, and
any foods causing GI irritation.
Report any black/tarry stools.
Tell prescriber if pregnant or
breastfeeding.
Bactericidal, inhibits
protein synthesis in
Headache, nausea, burning,
stinging, pain, pruritus, rash,
Do not use in burn patients, do not
get in eyes.
Antibacterial
Clopridogrel
Plavix
Anti-platelet agent
(1/2/14-1/6/14)
1 Tab daily PO
With meals.
Hold if Plt
<70,000
(hold if NPO)
susceptible bacteria.
Inhibits platelet
aggregation by inhibiting
ADP.
swelling, tenderness.
Upper resp tract infection,
chest pain, headache, flu like
symptoms, pain, dizziness,
diarrhea, rash, rhinitis,
depression
Metoprolol
Lopressor
Beta Blocker
50 mg daily PO
25 mg daily PO
Hold if SBP<110
(hold if NPO)
Blocks response to the
beta adrenergic
stimulation. Selective for
B1 receptors no effect on
B2. Lowers BP.
Orthostatic hypertension,
drowsiness, dizziness,
headache, diarrhea,
bradycardia, pruritus, heart
failure, hypotension
Docusate Sodium
Colace
Laxative
100 mg PO daily
Hold for diarrhea
(hold if NPO)
Promotes incorporation
of water into stool,
increases fecal mass.
Softens stool.
Aspirin
Baby Aspirin
Antiplatelet agent
81 mg PO daily
with meal.
(hold if NPO)
Inhibits prostaglandin
synthesis. Inhibits
platelet aggregation,
with antipyretic and
analgesic activity.
Decreases clot formation
in blood stream.
Electrolyte imbalance
Dehydration
Abdominal cramps, nausea,
vomiting, diarrhea, rashes,
urine discoloration.
Angioedema,
bronchospasm, GI pain &
bleeds, Hepatotoxicity,
hearing loss, bleeding,
Pulmonary edema
Magnesium Oxide
Mag-Ox 400
Antacid
400 mg PO BID
Hold if Mag >3
(hold if NPO)
Mineral, when combined
with water which acts as
an antacid, counteracting
stomach acid with its
alkaline properties.
Diarrhea
GI irritation
Warn patient about risks of bleeding
and what to watch for when on an
anti-platelet, including bleeding from
mucosa, excessive bleeding, or
uncontrolled bleeding.
Teach patient to use a soft toothbrush
and an electric razor to minimize risk
of blood loss.
Monitor BP and HR. Do not crush or
chew. Watch for orthostatic
hypotension when standing. Teach
patient to rise slowly from rest, and
warn of effects of dizziness and
tiredness with this medication.
Medication may mask the signs of
hypoglycemia; make sure to test
blood sugar often.
Long-term use may cause
dependence.
Drink plenty of water with use of
laxatives.
Warn patient about risks of bleeding
and what to watch for when on an
anti-coagulant, including bleeding
from mucosa, excessive bleeding, or
uncontrolled bleeding.
Teach patient to use a soft toothbrush
and an electric razor to minimize risk
of blood loss.
Keep serum magnesium between
1.5-2.5.
May have a laxative effect
Caution with renal impairment
increasing absorption/ decreasing
Furosemide
Lasix
Diuretics
20 mg IV BID
Loop diuretic that
inhibits reabsorption of
Na and Cl ions causing
increases in water,
calcium, magnesium,
sodium and cl.
Used to replace serum
potassium and prevent
hypokalemia especially
with use of a diuretic.
Hyperuricemia,
hypokalemia, anemia,
diarrhea, glycosuria,
headache, hypocalcemia,
hypomagnesemia,
hypotension, ototoxicity.
Ab pain, diarrhea,
flatulence, nausea, vomiting,
arrhythmia
KCl
K-dur
Electrolyte replacement
20 mEq BID PO
with meals
Hold if K> 4.7
(hold if NPO)
Thiamine
Vitamin B1
B Vitamins
100 mg daily PO
(hold if NPO)
Needed for carbohydrate
and pyruvate
metabolism. Functions as
a vitamin.
Collapse, pulmonary edema,
nausea, diarrhea,
angioneurotic edema,
anaphylaxis.
Folic Acid
Folvite
Vitamin
2 mg daily PO
(hold if NPO)
Needed for
erythropoietin synthesis
and to increase levels of
RBC, WBC, and
platelets. Helps fight
anemia. Especially
important in this pt. to
hopefully make it so he
will not become too
anemic without a blood
transfusion.
Bronchospasm, flushing
excretion time.
Warn patient not to take supplement
on an empty stomach.
May lead to excessive electrolyte and
water depletion, use caution.
Use caution with Diabetes, SLE,
liver disease, renal impairment.
Assess for S&S of hypo and
hyperkalemia.
Monitor pulse, ECG, BP throughout
therapy
Mix with juice or other fluids to
decrease unpleasant taste.
Look for absence of nausea and
vomiting, anorexia, insomnia, muscle
weakness.
Teach about including vitamin B rich
foods in diet such as seeds, nuts, fish
and enriched grains.
Monitor signs and symptoms of
anemia, and expect to see an increase
in energy level, a decrease in
sensitivity to cold and other anemic
signs.
Teach about eating foods high in
folic acid such as beans, legumes and
dark leafy green vegetables.
Explain to the patient that by taking
his folic acid vitamin and eating folic
acid rich foods, he may be able to
keep his blood counts high enough to
not require a transfusion.
Explain to the patient that these
vitamins are not a blood product (just
Ferrous Sulfate
Feratab
Iron Products
325 mg BID PO
with meals
(hold if NPO)
Replaces iron stores
needed for proper RBC
development in order to
treat iron deficiency
anemia.
Nausea, constipation,
epigastric pain, black/red
tarry stool, vomiting and
diarrhea, discolored teeth &
eyes.
Atorvastatin
Lipitor
Statin
10 mg qhs PO
(hold if NPO)
HMG-CoA reductase
inhibitor. Inhibits
synthesis of cholesterol
due to competitive
inhibition.
Headache, chest pain,
peripheral edema, sinusitis,
diarrhea, weakness, rash,
back pain
Lisinopril
Prinivil
ACE inhibitor
10 mg daily PO
Hold if SBP<110
(hold if NPO)
Dizziness, cough, headache,
hyperkalemia, diarrhea,
hypotension, chest pain,
fatigue, nausea and
vomiting, rash
Insulin Aspart
NovoLog
Insulins
Dose Sched: AC& qhs
Prevents conversion of
angiotensin1 to
angiotensin 2 through
inhibition of angiotensin
converting enzyme.
Decreases BP through
vasoconstriction,
increased renin activity
and decreased
aldosterone production.
Diabetes
Blood Sugar Control
FSBS
Dose
70-130
131-180
181-240
241-300
0 units
4 units
8 units
10 units
Hypoglycemia, allergic
reactions including
anaphylaxis, erythema,
pruritus, swelling.
in case!)
Watch for signs and symptoms of
toxicity such as nausea and vomiting,
diarrhea, hematemesis, pallor,
cyanosis, shock, coma.
Teach patient that the iron
supplement may make his stool dark
or red, and to not be concerned.
Also explain to the patient that he
may experience staining of his teeth
so try to take the supplement (if
liquid) through a straw.
Teach patient that he can take the
vitamin with food if it upsets his
stomach.
Increased blood sugar and increased
HBA1c may occur. Monitor with
FSBS and cover with insulin
Humalog.
Risk of rhabdomyolysis
Risk of myopathy
Monitor BP and HR. Watch for
orthostatic hypotension when
standing. Teach patient to rise slowly
from rest, and warn of effects of
dizziness and tiredness with this
medication.
Assess for symptoms of
hypoglycemia including: anxiety,
restlessness, tingling in hands and
feet, chills, cold sweats, confusion,
cool, pale, skin, difficulty in
301-350
351-400
>400
Edema, headache, fatigue,
palpitations, dizziness,
nausea, flushing, abd pain,
somnolence
concentration, Drowsiness,
nightmares, trouble sleeping,
excessive hunger, headache,
nervousness.
Overdose is manifested by signs of
hypoglycemia. Teach pt. to become
aware of hypoglycemia reactions.
May worsen angina and acute
myocardial infarction. Monitor pain
levels and give nitroglycerin as
needed. Edema may develop.
Headache, Malaise,
Diarrhea, Dizziness,
Constipation, Torsades de
Pointes.
Assess for nausea, vomiting,
abdominal distention, and bowel
sounds before and after drug is
given.
EPS,Fatigue, restlessness,
sedation, diarrhea, nausea,
galactorrhea, gynecomastia
Watch for S&S of extrapyramidal
rxn including tardive dyskinesia. Do
not administer for longer than 12
weeks.
Confusion, dizziness,
sedation, hypotension,
constipation, dyspepsia,
nausea, tolerance,
dependence, dry mouth,
respiratory depression
Administration on a regular basis
often decreases pain a lot more than
PRN.
Assess RR regularly
Give medication before pain
becomes severe.
Assess pain on a pain scale of 1-10.
No more than 3grams daily of
acetaminophen may be taken due to
liver failure.
12 units
16 units
16 units
CALL
MD!!
Amlodipine
Norvasc
Calcium Channel Blockers
5 mg PO @1800
daily.
Hold if SBP <110
(hold if NPO)
Ondansetron
Zofran
Antiemetic
PRN: N&V
4mg IV q6h
Metoclopramide
Reglan
Antiemetic
PRN: N&V (if
Hydrocodone/APAP
Norco
Opioid Analgesic
PRN: pain 6-8
5/325mg PO q4h
(Do not give if
NPO)
Zofran doesn’t work)
q4h IV
Inhibits calcium ions
from travelling across
membranes of
myocardial cells
inhibiting cardiac and
vascular smooth muscle.
Blocks effects of
serotonin at sites located
throughout the vagal
nerve terminals
decreasing nausea.
Blocks dopamine
receptors in the
chemoreceptor trigger
zone of CNS and
sensitizes tissue to Ach,
increasing upper GI
motility and lower
sphincter tone.
Binds opiate receptors in
the CNS, produces
generalized cns
depression.
Morphine
Morphine
Opioid Analgesic
Dobutamine
Dobutrex
Inotropics
Nitroglycerin
Hydralazine
PRN: pain 7-10
2mg IV q4h
Binds to opiate receptors
in the CNS
PRN: To wean CI
over 2.3.
Stimulates beta
adrenergic receptors with
minor effects on HR or
periphery. Increases CO
without increasing HR.
250mg/250ml D5W
Conc: 1mg/ml
Rate: 1-2 mcg/kg/min
q10 min
Max: 10mcg/kg/min
1-6-14 (new order):
1mg STAT, off in 12
hr (2000)
PRN: to maintain
post op parameters
SBP > 95 & MAP 7075.
50mg/250ml D5W
Conc: 0.2 mg/ml
Rate: 5mcg/min
q2-5 min IV
PRN: SBP>140 or
MAP> 75
Hold if SBP<100
10mg IV q4h
Confusion, sedation,
hypotension, constipation,
Respiratory depression,
Hypertension, increased HR,
PVC, SOB, headache,
nausea and vomiting, angina
Turn and move slowly to decrease
risk for orthostatic hypotension.
Sugarless gum and candy reduce risk
of dry mouth.
Be aware of respiratory depression
with too many CNS depressants
given to patient.
Monitor BP and HR, ECG, PCWP,
CO, CVP, and urinary output.
Palpate peripheral pulses and notify
physician if pulse deteriorates or
extremities become cold and
clammy.
Causes systemic
vasodilation which
decreases the preload and
myocardial 02 demand,
decreasing angina pain.
Headache, hypotension,
tachycardia, dizziness,
methemoglobinemia,
syncope, increase bleeding
time, unstable angina,
rebound hypertension,
thrombocytopenia.
Monitor BP and HR. Watch for
orthostatic hypotension when
standing. Teach patient to rise slowly
from rest, and warn of effects of
dizziness and tiredness with this
medication.
Vasodilates SM by direct
relaxation, decreases BP
(for HTN) with an
increase in HR, SV, and
CO.
Headache, tremor, dizziness,
anxiety, palpitations, reflex
tachycardia, angina, nausea
and vomiting, anorexia,
diarrhea and shock,
leukopenia, agranulocytosis,
thrombocytopenia.
Monitor BP, JVD, and pulse.
Monitor electrolyte studies, and
glucose studies and this medication
may cause hyperglycemia. Assess for
lupus like symptoms.
Monitor daily weights and I&O,
edema and lung sounds.
Monitor orientation.
Beware of signs of impending
infection. Use proper hand washing.
1.) Diagnosis: Acute pain and discomfort RT
CABG surgery AEB verbal pain rating of
8/10.
Data to Support:
CABG surgery
Restlessness
Mediastinal wound with 2 chest tubes.
3 incisions on left donor leg, closed with
staples.
Pt states acceptable pain at 4.
Pain score 6/10, 8/10 when awake.
Pain Medications Administered
Hydrocodone/APAP
Morphine
Pt. splinting area when coughing
Expected Outcome/Goals:
Pt. will be able to manage pain at below a
4/10 with use of PO hydrocodone/APAP.
Pt. will not require further use of morphine.
Pt. will state being more comfortable at rest,
and will appear less restless.
2.) Diagnosis: Risk for infection RT impaired
skin integrity at mediastinal wound and left
donor leg incisions.
Data to Support:
Mediastinal incision, left donor leg incisions
Wounds clean & dry
WBC: 18.2
NPO/Clear Liquid Diet
Albumin: 3.1; 2.7
Type 2 diabetes
Blood Sugar: 165,130,143
1800 ml sero-sanguineous drainage (1/6-1/7)
Urinary Catheter
Lengthy hospital stay
Expected Outcome/Goals:
Pt. will not show any signs and symptoms of
infection during hospital stay (fever, redness or
warmth at surgical incision sites).
Pt’s WBC, and albumin labs will return back to
within normal range.
Nurses will use proper hand washing techniques
before seeing pt.
Catheter will be removed as soon as possible.
Admitting Diagnosis: STEMI
Priority Assessments: BP, O2 sat, CBC, Pain,
Blood sugar, wound assessment, I&O
5.) Knowledge:
 Patient will be able to show me how to properly use an incentive
spirometer.
 Patient will be able to tell me one food containing each of the
following vitamins: Iron, Folic Acid and vitamin B12.
 Patient will be able to show me how to do ankle and wrist
pumps given to him by OT.
 Patient will explain the importance of Plavix and aspirin & will
be able to describe the signs and symptoms of an internal bleed.
3.) Diagnosis: Risk for ineffective tissue
perfusion RT anemia with refusal of blood
products.
Data to Support:
RBC: 3.22
Hct: 29.5
Hgb: 9.9
Prescribed:
Ferrous Sulfate
Folic Acid
Thiamine (B-12)
Refusal of blood products: due to religious
beliefs- Jehovah’s Witness
1800 ml sero-sanguineous drainage 1/6-1/7
Fatigue
Hx of alcohol abuse
Pt states drinking 6-7 beers daily
O2 sat: 94-98; BP (ave): 101/60
Expected Outcome/Goals:
Pt’s blood labs will return back to within
normal limits
Pt will deny feeling overly tired or cold
Pt will be able to explain 3 different types of
food that are high in Iron, Folic Acid and
Vitamin B-12.
Pt will not experience any further drop in
blood lab levels.
4.) Discharge
 Patient’s pain will be managed at a level <4 with use of
Norco.
 Patient’s labs will return back to within defined limits.
 Patient will not be experiencing any signs or symptoms
of infection.
 Patient will be gradually increased back to a regular
diet before discharge.
 Patient will be able to get up and out of bed without
complete assistance before discharge
Evaluate Effects of Nursing Actions – Patient Response/Outcomes
Chief Medical Diagnosis: STEMI
Priority Assessments: BP, O2 sat, CBC, Pain, Blood sugar, wound assessment, I&O
1. Nursing Care: Acute pain and discomfort RT
CABG surgery AEB verbal pain rating of 8/10.
Nursing Actions:
Initial Assessment: checked vital signs and pain level.
Patient Response and Outcome:
Rotated patient to left side.
Patient tolerated procedure and went back to sleep.
Check on patient, ask pain level.
Patient requests warm blanket. States pain at a zero
Got patient up to walk.
Patient requires a lot of assistance to walk, including 3
nurses. Gets very exhausted going down the hall in the
hospital and requests to go back to sleep.
Reassess vital signs
Vitals: T:97.8, P: 82, R:20, O2: 94, BP: 105/62. Patient
states pain still at a 0/10.
Initial assessment (day 2)
Vital Signs: T: 98, P: 86, R:18, O2: 95, BP: 103/63
Pain: 6/10.
Patient given 5/325mg of Norco
Patient tolerated medication administration, and
continued watching TV.
Reassessed pain level 30 minutes later.
Patient states pain 3/10. States feeling very tired.
Allowed patient to rest until right before dinner.
Got patient up to walk.
Patient able to walk much further than the previous
day. Also seems to need much less help than
previously. Patient returned to chair.
Check on patient
2. Nursing Care: Risk for infection RT impaired skin
integrity at mediastinal wound and left donor leg
incisions.
Nursing Actions:
Performed proper hand hygiene
Patient asleep.
Patient Response and Outcome:
Initial Assessment
Wound was clean, dry with edges well approximated.
No dehiscence noted. No signs or symptoms of
infection were present including warmth or redness in
the area, no drainage in the left donor site. Two
mediastinal chest tubes exiting the mediastinum were
draining sero-sanguineous fluid, which was expected at
Vital Signs: T:97.2, P:85, R:16, O2:94, BP: 112/68.
Patient states he is in no pain, states he is still very
tired.
this time.
Vital Signs: T:97.2, P:85, R:16, O2:94, BP: 112/68.
Patient’s vitals show no signs or symptoms of infection
at this time.
Provide Foley Catheter Care
Provided catheter care to the patient in order to
maintain cleanliness of Foley site. Patient tolerated
procedure well.
Reviewed patient’s labs
WBC levels elevated possibly showing that patient is
fighting an infection. Will continue to monitor for
signs and symptoms of infection. Albumin level also
low showing evidence for delayed wound healing. Will
continue to monitor surgical sites for signs of delayed
wound healing.
Checked pt’s blood sugar
Blood sugar: 165.
Covered patient’s blood sugar with 4 units insulin
Patient tolerated medication administration, no adverse
events noted.
Changed dressing
Dressing was soiled so nurse changed 3 dressings on
left donor site before bed. Practiced great hand hygiene
before and after dressing change and used sterile
technique.
Patient Response and Outcome:
3. Nursing Care: Risk for ineffective tissue perfusion
RT anemia with refusal of blood products.
Nursing Actions:
Initial Assessment:
T:97.2, P:85, R:16, O2:94, BP: 112/68. Patient is
stating he is very tired. Perfusion looks good right
now, however the patient’s fatigue could be due to low
hgb & RBC.
Lower lights and provide relaxing atmosphere for rest. Patient asleep.
Ask visitors not to disturb patient while resting.
Check on patient.
Patient requesting a warm blanket. Brought patient a
warm blanket and turned patient to the left side.
Measured output from chest tube
Chest tube drained approximately 1000 ml of serosanguineous blood on 1/6/14, and 800ml on 1/7/14.
Go for a walk
Patient required a lot of rousing to wake him. Needed a
lot of assistance to get out of bed, and followed patient
with a chair in case he got too tired. Brought patient
back to bed to rest.
Reassess patient
Vitals: T: 97.8, P: 82, R:20, O2: 94, BP: 105/62.
Patient still seems to be very lethargic.
Student Clinical Self-Appraisal
Weekly (turn in with Care Plan/Map)
Student Vanessa Van Steyn
Course Nurs 4810
Instructor Jo Sokolo
Instructions: Please evaluate your performance during clinical today using the following concepts:
Patient Advocate
Professional Demeanor
Flexible
Critical Thinking
Communication/rapport
Peer Support
Self-Initiated
Team Player
Skill Acquisition
Safety
Organized
Educator
Leadership
Well-prepared
Dependable
Nursing Process
Knowledgeable
Areas of Strength Today (1/6/14-1/7/14)
Flexible
Once my day nurse’s shift was over, I got a new nurse
whose main responsibility was preparing the newly
deceased patient for the morgue. I felt that I was up for
the challenge and glad I was flexible enough to take up
the new task.
Skill Acquisition
I prepped the newly deceased patient, inserted a foley
basically by myself, and worked a lot with cardiac drips
and cardiac measurements. Overall, it was a good week!
Instructor Comments:
Areas Needing Growth-Include plan of
improvement
Professional Demeanor
I felt that the code blue was a little unprofessional as
the staff was not very sensitive to the patient’s
family when discussing the patient’s status. I also
felt that the staff was a little too jokey when
prepping the body, but it could have been a coping
mechanism. Next time, I will definitely try to
maintain the respect I feel the patient deserved.
Safety
I wasn’t fitted with a mask specially used for H1N1,
and didn’t realize how close I was standing next to
the door during the code. Also, I feel that because I
was working with two HIV+ patients this week, I
should have been a lot more observant about what I
was doing, although no adverse events occurred.
Next time I will discuss safety with my nurse more
clearly.