CSU STANISLAUS, B.S.N.
CLINICAL PLAN OF CARE
Student
Erica Anacleto
Date of Care
2/27/2014
Room Number
215-2
Patient Data
Patient Initials
B.D.
Gender
Male
Age
Height
1.91 m (75 in)
Weight
82.1 kg (192.3 lbs)
Spirituality
Catholic
Ethnicity
White
Admitting Diagnosis
PVD w/ significant ischemic ulceration of the left lower leg and referred for a PTA (percutaneous transluminal angioplasty, patient in
persistent pain, rule out sepsis, exhibiting SOB, rule out heart failure.
Admitting Date
2/13/2014
Post-Op Day (POD)
55yo (5/6/1958)
11th day (Surgery on 2/16/14)
Vital Signs
T (max)
0930 - 36.7 C
1100 - 36.5 C
P
70
81
R
WNL with O2
18 bpm
B/P
156/65
131/61 (80)
O2 Sat.
98% on 2LPM nasal
prongs
90-91% on room air
Pain Scale
No pain 0
No pain 0
History Related to this Admission
Significant ischemic ulceration of the left lower left leg, Possible sepsis, deteriorating condition, Pain management, uncontrolled Diabetes Mellitus
(hyper/hypoglycemia), dorsal pedal pulse absent in left foot and posterior tibial pulse in left foot ¼.
Past Medical History
Severe uncontrolled diabetes mellitus, uncontrolled hypertension, uncontrolled hyperlipidemia, COPD (tobacco user), CAD, carotid vascular disease with left
carotid artery occlusion, endocarditis, PVD with non-healing ulcers in both legs, iritis inactive, anxiety disorder, depression.
Surgical History
Prosthetic aortic valve (date unknown). Last bilateral leg intervention done on both legs 8/2010. Multiple stents in coronary arteries (date unknown).
CLINICAL PLAN OF CARE
Diet
ADA diet
Activity
Advance Directive
Unknown
Foley
N/A
Drains/Tubes
Bed rest, Ambulate
around unit
Once every shift & upon
return from procedures
Wound VAC
Code Status
Full
VS Frequency
NG/Feeding Tube
N/A
Glucose Monitoring
Yes
DVT Prophylaxis
Ambulation
PCA/Epidural
N/A
Telemetry
N/A
Vascular Access
IV Site:
PICC line in Left brachial arm
IV Solution:
N/A (only flushing)
Vascular Access
IV Site
N/A
IV Solution
N/A
Safety Considerations
Fall Risk, IV left brachial arm, nasal prongs 2LPM, wound vac on amputated digit
Dressing Changes
Twice weekly on amputated toe and IVC site to be changed today 2/27/14
Respiratory Treatments
Oxygen via nasal prongs at 2LPM, respiratory spirometer
Labs for clinical day
Blood Glucose and submit pleural fluid to lab for cytology
Scheduled Procedures
U/S guided Right thoracentesis in radiology with sedation
Procedures done this
admission
pRBC transfusion, FFP transfusion, left and right thoracenetsis, left big toe amputation and debridement, PICC line placement.
Allergies
NKDA
Medications
Generic & Trade Name
Drug Classification
(Therapeutic &
Pharmacologic)
Acetaminophen (Tylenol)Analgesic, Antipyretic &
nonopioid analgesic
Acetaminophen/Codeine
Phosphate (Tylenol #3) –
Analgesic, antipyretic &
nonopioid analgesic
Acetaminophen/Hydrocodo
ne Bitart (Norco 7.5-325) –
Analgesic, antipyretic,
antiflammatory & opioid
analgesic combo
Dose/Route
Frequency
Action of drug and Rationale
(Why is patient on
medication?)
Significant
Side Effects
(Serious and/or frequent)
Nursing implications related to
assessment, administration or
education
650 mg PO Q4H
PRN
Reduce pain by means of
inhibiting prostaglandin
synthesis in CNS. Pt on
medication for mild pain.
Liver toxicity, rash, nausea,
headache, analphlactic
reaction, anemia,
thrombocytopenia, renal
tubular necrosis
1 each PO Q4H
PRN
Codeine: Opioid agonist;
analgesia; blocks pain
impulse generation and
inhibits ascending pain
pathways, thus altering the
perception and response to
pain. Tylenol: reduce pain
by means of inhibiting
prostaglandin synthesis in
CNS. Pt on medication for
mild to moderate pain postoperatively.
Hydrocodone binds to
carious opioid receptors
producing analgesia and
sedation, acetaminophen
exact mechanism of action
unknown
Drowsiness, lightheadedness,
dizziness, sedation, SOB,
nausea, vomiting, euphoria,
dysphoria, constipation, abd
pain, pruritus, rash,
thrombocytopenia,
agranulocytosis, respiratory
depression.
Teach pt common side effects
of medication and instruct pt to
not take other substances
containing acetaminophen
because of toxicity, monitor
patient for adverse effects,
assess for pain prior and post
administration, do not
administer more than 4g/day
Teach pt common side effects
of medication and instruct pt to
not take other substances
containing acetaminophen
because of toxicity, monitor
patient for adverse effects,
assess for pain prior and post
administration, keep HOB
elevated, assess bowel
sounds, do not administer
more than 4 g/day of Tylenol
2 tab PO Q6H PRN
Drowsiness, constipation,
nausea, respiratory
depression
Teach pt side effects of drug,
may cause constipation, tell
them to report any pain, or abd
pain, teach pt safety concerns
with drowsiness, effects of
drugs, ambulate slowly and
call for assistance, monitor pt
for pain via pain scale, assess
bowel sounds, I & Os, monitor
safety precaution’s because
sedative quality of drug, do no
exceed 4 g in 24 hrs of Tylenol
from all sources.
Acetaminophen/Hydrocodo
ne Bitart (Norco 5-325) –
Analgesic, antipyretic,
antiflammatory & opioid
analgesic combo
1 tab PO Q4H PRN
Hydrocodone binds to
carious opioid receptors
producing analgesia and
sedation, acetaminophen
exact mechanism of action
unknown
Drowsiness, constipation,
nausea, respiratory
depression
Albuterol Sulfate (Accuneb
0.083%) – Beta2 agonist,
bronchodilator
2.5 mg NEB Q4H
PRN
It is a Beta-2 receptor
agonist with some beta-1
activity. Pt on medication
for acute bronchospasm.
Alprazolam (Xanax) –
Antoanxiety agent,
anxiolytics,
benzodiazepines
0.25 mgPO Q12H
PRN
Binds receptors at several
sites within the CNS,
including the limbic system
and reticular formation. Pt
on medication for anxiety.
Tremors, nausea, fever,
bronchospasm, vomiting,
headache, dizziness, cough,
UTI, increased appetite, dry
mouth, pain, dyspepsia,
hyperactivity, nervousness,
sweating, epistaxsis,
epigastric pain, tachycardia,
increased blood glucose levels
Drowsiness, depression,
headache, constipation,
diarrhea, dry mouth,
tachycardia, confusion,
insomnia, nausea/vomiting,
hypotension, blurred vision,
syncope, nervousness, tremor,
nasal congestion
25 mg PO Daily
SCH
Blocks response to betaadrenergic stimulation;
cardioselective for beta 1
receptors at low doses, with
little or no effect on beta 2
receptors. Pt on medication
for hypertension.
Atenolol (Tenormin) – Beta
blockers, beta-1 selective,
antihypertensive
Tiredness, hypotension,
bradycardia, cold extremeties,
postural hypotension,
depression, nausea, diarrhea,
fatigue, vertigo,
lightheadedness, dyspnea, AV
block.
Teach pt side effects of drug,
may cause constipation, tell
them to report any pain, or abd
pain, teach pt safety concerns
with drowsiness, effects of
drugs, ambulate slowly and
call for assistance, monitor pt
for pain via pain scale, assess
bowel sounds, I & Os, monitor
safety precaution’s because
sedative quality of drug, do no
exceed 4 g in 24 hrs of Tylenol
from all sources.
Teach pt side effects of drug,
may cause tremors, headache,
dizziness and nervousness,
tell them to ambulate slowly
and call for assistance,
monitor pt for pain and fever,
monitor BS post treatment,
keep HOB elevated
Teach pt side effects of drug,
may cause insomnia, tremors,
nasal congestion, constipation
or diarrhea and
nausea/vomiting, tell them to
ambulate slowly and call for
assistance, tell them to report
any abd pain, monitor pt for
hypotension, tachycardia and
confusion, keep HOB elevated
and assess bowel sounds.
Teach pt side effects of drug,
may cause nausea, diarrhea
and tiredness, tell them to sit
up slowly from lying position
and ambulate slowly, monitor
for hypotension, bradycardia,
vertigo and dyspnea.
Bisacodyl (Dulcolax) –
laxative, stimulant
10 mg PR X1 PRN
Ciprofloxacin (Ciloxan) –
Quinolones, ophthalmic
solution
1 drop RIGHT EYE
TID PRN
Dextrose (D50w) –
Glucose elevating agent
12.5 gm IV PUSH
per parameter PRN
Dextrose (D50w) –
Glucose elevating agent
25 gm IV PUSH per
parameter PRN
Irritates the smooth muscle
of the intestine and possibly
the colonic intramural
plexus, which in turn
increases peristalsis.
Increases intestinal fluid
accumulation and laxation
by altering water and
electrolye secretion. Pt on
medication for constipation.
Absorption through the
cornea into acqueous
humor; enhanced in
presence of ocular
inflammation &/or epithelial
defects; some systemic.
Unsure why pt on
medication, indications for
medication are for bacterial
conjunctivitis or corneal
ulcers (keratitis).
Parenteral dextrose is
oxidized to carbon dioxide
and water, and provides 3.4
cal/gram of d-glucose. Pt
on medication PRN for
hypoglycemia.
Parenteral dextrose is
oxidized to carbon dioxide
and water, and provides 3.4
cal/gram of d-glucose. Pt
on medication PRN for
hypoglycemia
Abdominal cramping,
excessive diarrhea, electrolyte
and fluid imbalance, rectal
burning, vertigo, nausea,
vomiting.
Teach pt side effects of drug,
may cause abdominal
cramping, vomiting, diarrhea,
tell pt to ambulate slowly due
to vertigo and call for
assistance, monitor pt for
electrolyte and fluid imbalance,
keep HOB elevated.
Burning, stinging, lid margin
crusting, crystals/sclaes on
eyelashes, foreign body
sensation, itching, conjunctival
hyperemia, ocular discomfort,
lid edema, tearing,
photophobia, decrease in
vision, corneal infiltrates,
keratopathy.
Teach pt side effects of drug,
itching, burning, stinging,
ocular discomfort and tell pt to
avoid rubbing eye and to call
for assistance when
ambulating as a decrease in
vision can occur. Monitor pt
for lid edema, conjunctival
hyperemia and decreased
vision.
Hyperosmolarity,
hypervolemia, phlebitis,
pulmonary edema, cerebral
hemorrhage, cerebral
ischemia, hyperglycemia,
injection site extravasation.
Teach pt effects of drug and
that it will only be administered
in the event that the pt is
severely hypoglycemic,
monitor pt for s/s of cerebral
hemorrhage &/or ischemia,
monitor BS post
administration, and inspect IV
site.
Teach pt effects of drug and
that it will only be administered
in the event that the pt is
severely hypoglycemic,
monitor pt for s/s of cerebral
hemorrhage &/or ischemia,
monitor BS post
administration, and inspect IV
site.
Hyperosmolarity,
hypervolemia, phlebitis,
pulmonary edema, cerebral
hemorrhage, cerebral
ischemia, hyperglycemia,
injection site extravasation.
Generic & Trade Name
Drug Classification
(Therapeutic &
Pharmacologic)
Dextrose (D5w) –
crystalloid fluid that has 5%
dextrose in water,
intravenous volume
expander
Dextrose (D10w) –
crystalloid fluid that has
10% dextrose in water,
intravenous fluid expander
Dose/Route
Frequency
Action of drug and Rationale
(Why is patient on
medication?)
Significant
Side Effects
(Serious and/or frequent)
Nursing implications related to
assessment, administration or
education
1,000 mls @ 75
mls/hr IV Q13H20M
PRN
Hypertonic solution that
raises total fluid volume,
helpful in rehydrating and
excretory processes,
provides a source of
calories, it pulls the fluid
into the vascular by
osmosis resulting in an
increase in vascular
volume. Unsure why pt
receiving D5W, indications
for this therapy is for a
source of water, electrolytes
and calories. Used for
hypertonic hydration and to
replace extracellular fluid
losses.
Hypertonic solution that
raises total fluid volume,
helpful in rehydrating and
excretory processes,
provides a source of
calories, it pulls the fluid
into the vascular by
osmosis resulting in an
increase in vascular
volume. Unsure why pt
receiving D5W, indications
for this therapy is for a
source of water, electrolytes
and calories. Used for
hypertonic hydration and to
replace extracellular fluid
losses.
Hypervolemia (fluid overload),
pain (phlebitis at injection site),
hyperglycemia and glycosuria.
Teach pt that administration of
this IV fluid will help with
rehydration, teach pt effects of
the fliud, monitor pt for fluid
overload, auscultate lungs pre,
during and post fluid
administration, monitor IV site
for pain and monitor BS during
infusion and post infusion.
Hypervolemia (fluid overload),
pain (phlebitis at injection site),
hyperglycemia and glycosuria.
Teach pt that administration of
this IV fluid will help with
rehydration, teach pt effects of
the fliud, monitor pt for fluid
overload, auscultate lungs pre,
during and post fluid
administration, monitor IV site
for pain and monitor BS during
infusion and post infusion.
1,000 mls @ 100
mls/hr IV Q10H
PRN
Docusate Sodium
(Colace)-laxative, stool
softner
100 mg PO DAILY
SCH
Surfactant laxative, which
reduces tension of oil-water
interface of the stool;
enhances incorporation of
water and fat into stool,
causing stool to soften. Pt
on this medication for
constipation.
Abdominal cramping, diarrhea,
excessive bowel activity,
intestinal obstruction, throat
irritation.
Famotidine (Pepcid) –
Histamine H2 antagonist,
acid controller
20 mg DAILY SCH
Blocks H2 receptors of
gastric parietal cells,
leading to inhibition of
gastric secretions. Unsure
why pt is receiving this
medication, indications for
use are for duodenal ulcer,
benign gastric ulcer, GERD,
hypersecretory conditions,
heartburn.
Loop diuretic; inhibits
reabsorption of sodium and
chloride ions at proximal
and distal renal tubules and
loop of Henle; by interfering
with chloride-binding
cotransport system, causes
increases in water, calcium,
magnesium, sodium, and
chloride.
Headache, constipation,
diarrhea, dizziness, anxiety,
arrhythmia, confusion,
insomnia, nausea, pruritus,
vomiting, musculoskeletal
pain.
Furosemide (Lasix) – Loop
diuretic
40 mg IV PUSH
DAILY SCH
Loop diuretic; inhibits
reabsorption of sodium and
chloride ions at proximal and
distal renal tubules and loop of
Henle; by interfering with
chloride-binding cotransport
system, causes increases in
water, calcium, magnesium,
sodium, and chloride.
Teach pt side effects of drug,
abdominal cramping, intestinal
obstruction and throat
irritation, tell pt to report any
abdominal pain, assess bowel
sounds, monitor I & O’s,
monitor s/s of intestinal
obstruction (similar to
appendicitis).
Teach pt side effects of drug,
tell pt to ambulate slowly and
call for assistance if dizzy,
elevate HOB, monitor pt for
pain, assess bowel sounds,
assess heart sounds.
Teach pt effects of medication
and to report any SOB or
hearing impairment, as well as
any other side effects
immediately, tell pt to
ambulate slowly, keep urinal
next to bed, monitor I & O’s,
monitor electrolytes, BUN and
Hgb/Hct as ordered per MD,
monitor for s/s of
hypocalcemia, hypokalemia,
hypomagnesemia and anemia,
monitor BS and VS especially
BP
Gabapentin (Neurontin) –
Anticonvulsants, GABA
analogue, nonopioid
analgesic
300 mg PO TID
SCH
GABA analogue;
structurally related to
neurotransmitter GABA, but
has no effect on GABA
binding, uptake, or
degradation; mechanism for
analgesic and
anticonvulsant activity
unknown. Unsure why pt
on this medication, but most
likely for diabetic
neuropathy.
Glucagon (Glucagon) –
Hypoglycemia antidote,
used in GI diagnostics,
glucose elevating agent
1 mg IM PER
Parameter PRN
Glucose (Glucose 15) –
Hypoglycemia antidote
1 tube PO PER
parameter PRN
Insulin antagonist,
stimulates cAMP synthesis
to accelerate hepatic
glycogenolysis and
gluconeogenesis, also
relaxes smooth muscles in
GI tract. Pt receiving
medication as PRN for
hypoglycemia.
A monosaccharide that
work quickly to raise the
glucose level in the blood.
Pt receiving PRN in the
event the pt experiences
severe hypoglycemia.
Ataxia, dizziness, fatigue,
diplopia, somnolence,
insomnia, nervousness,
nystagmus, tremor, amblyopia,
back pain, vomiting, nausea,
constipation, depression, dry
mouth, dysarthria, dyspepsia,
increased appetite,
leukopenia, myalgia,
nervousness, peripheral
edema, angioedema,
vasodilation, pruritus,
pharyngitis, blood glucose
fluctuation, elevated liver
function tests, HTN, vertigo.
Occasional nausea and
vomiting, rash, hypotension,
tachycardia.
Severe allergic reactions
include; rash, hives, itching,
difficulty breathing, tightness in
chest, swelling of mouth, face,
lips, or tongue.
Teach pt side effects of this
drug, instruct pt to take with
food, tell pt to report any signs
of facial swelling, SOB
immediately, maintain HOB
elevated and emesis pan
available at bedside, tell pt
ambulate slowly and call for
assistance, monitor for any
visual changes, check VS 3060mins post administration
and assess pain, monitor BS
and monitor liver enzymes.
Teach pt of side effects of drug
and that drug will only be
administered in the event of a
severe hypoglycemic event.
Maintain HOB elevated w/
emesis pain at bedside.
Monitor VS, BP and inspect pt
for any signs of a rash.
Teach pt effects that can occur
as a severe allergic reaction,
but otherwise there are no
common side effects. Inform
pt that this will only be given if
the pt experiences a severe
hypoglycemic event. Tell pt to
report any of the following
possible side effects. Monitor
BS post administration,
monitor for angioedema and
SOB.
Hydromorphone HCL
(Dilaudid) – Opioid
analgesic
0.5mg IV PUSH
Q4H PRN
Mu-opioid receptor agonist;
inhibits ascending pain
pathways, thus altering
response to pain; produces
analgesia, respiratory
depression, and sedation,
suppresses cough by acting
centrally in medulla. Pt
receiving medication PRN
for pain.
Imipenem/Cilastatin
Sodium 500 mg in Sodium
Chloride – Carbapenem
type antibiotic
100 mls @ 100
mls/hr IVPB Q6H
SCH
Inhibits bacterial cell-wall
synthesis by binding to
penicillin-binding proteins;
cilastatin prevents renal
metabolism of imipenem.
Pt on drug to stop the
bacterial growth from the
ulcerative lesion on the left
leg.
Anticholinergic: dry mouth,
palpitation, tachycardia, and
urinary retention.
Cardiovascular: angina,
bradycardia, cardiac arrest,
MI, syncope, shock, V-tach.
CNS; agitation, coma,
dizziness, dysphoria,
nervousness, restlessness,
sedation, depression.
GI: constipation, nausea,
vomiting, decreased appetite,
abdominal distention, GERD,
paralytic ileus.
Resp: resp depression,
hypoxia, resp arrest,
bronchospasm, dyspnea.
Other: flushing, pruritus,
sweating, urticaria, and
warmness of face/neck/upper
thorax.
Swelling, redness, pain, or
soreness at the injection site
may occur. Upset stomach,
nausea, vomiting, or diarrhea.
Dark urine, easy
bruising/bleeding, hearing
changes, confusion,
hallucinations, persistent sore
throat/fever, swollen tongue,
tingling hands/feet, yellowing
eyes/skin, muscle spasms,
unusual weakness, seizures,
anemia, hypotension,
neutropenia, increased PT,
elevated liver function tests.
Teach pt side effects of drug,
tell pt to report nausea
immediately so that an
antiemetic may be given to
ease with that symptom, tell pt
to ambulate slowly and call for
assistance, tell pt to report
SOB or flushing feeling of face
and thorax. Monitor VS,
assess pain 30-60 mins post
administration, assess
respirations frequently and for
s/s of respiratory depression,
assess bowel sounds and I &
O’s. If pt is known to become
nauseous with the drug,
administer an antiemetic prior
to administering Dilaudid.
Teach pt of side effects of
drug, dark urine,
bruising/bleeding, nausea,
swelling, muscle spasms. Tell
pt to ambulate slowly and call
for assistance. Maintain HOB
elevated, monitor VS, BP,
inspect eyes, skin, injection/IV
site, monitor liver enzymes,
CBC, Hgb/Hct, and Coag’s.
Generic & Trade Name
Drug Classification
(Therapeutic &
Pharmacologic)
Insulin Detemir (Levemir) –
Antidiabetic & Insulin,
intermediate to long acting
insulin
Dose/Route
Frequency
Action of drug and Rationale
(Why is patient on
medication?)
Significant
Side Effects
(Serious and/or frequent)
Nursing implications related to
assessment, administration or
education
80 unit SUBCUT
Bedtime SCH
Regulates glucose
metabolism, insulin and its
analogues lower blood
glucose by stimulating
peripheral glucose uptake,
especially by skeletal
muscle and fat, and by
inhibiting hepatic glucose
production; insulin inhibits
lipolysis and proteolysis and
enhances protein synthesis;
targets include skeletal
muscle, liver, and adipose
tissue. Pt has DM type 2
Stimulates peripheral
glucose uptake, inhibits
lipolysis and proteolysis
regulating glucose
metabolism – pt has DM
type 2
Hypoglycemia (shakiness,
palpitations, nervousness,
diaphoresis, anxiety, hunger,
pallor), headache, pallor,
nausea, urticaria,
hypokalemia, rash
Monitor pt BS, s/s of
hypoglycemia, give
appropriate time for meals,
and side effects of medication.
Teach pt importance of DM
management and use of
insulin pen, teach side effects
of medications, teach pt proper
diet that goes along with
insulin.
Hypoglycemia (shakiness,
palpitations, nervousness,
diaphoresis, anxiety, hunger,
pallor), hypokalemia, rash
Restores normal bowel flora
that inhibit growth of
harmful bacteria; stimulates
local immunity; promotes
water reabsorption in colon.
Pt on antibiotics.
Hives, chest tightness,
difficulty breathing,
angioedema
Monitor pt BS, s/s of
hypoglycemia, give
appropriate time for meals,
and side effects of medication.
Teach pt importance of DM
management and use of
insulin pen, teach side effects
of medications, teach pt proper
diet that goes along with
insulin.
Teach pt about possible side
effects and to call for
assistance immediately with
any signs of difficulty breathing
and angioedema or chest
tightness. Instruct pt to take at
least 2 hours after antibiotic
and to continue for several
days after antibiotic treatment
is finished.
Insulin Human Lispro
(Humalog) – Antidiabetic &
Insulin, Rapid acting insulin
0-24 unit SUBCUT
ACHS SCH P
Lactobacillus
Acidoph/Bulgaricus
(Lactinex) –
Gastrointestinal, Herbal,
Probiotic, digestion aid,
antidiarrheal properties
1 each PO TIDWM
SCH
Lactulose (Cephulac) –
Osmotic Laxative,
Ammonium Detoxicant
Lisinopril (Zestril) – ACE
inhibitor, Antihypertensive
20 gm PO BID SCH
20 mg PO DAILY
SCH
Constipation: Hyperosmotic
agent increases stool water
contents, softens stool,
promotes peristalsis, and
reduces blood ammonia
concentration.
Portal systemic
encephalopathy:
Breakdown of lactulose to
organic acids by colonic
bacteria acidifies colonic
contents, thereby
subsequently inhibiting
diffusion of ammonia back
to blood; agent also
enhances diffusion of NH3
from blood into gut, where it
is converted to NH4+.
Pt has had constipation.
Prevents the conversion of
angiotensin I to angiotensin
II (a potent vasoconstrictor)
through competitive
inhibition of angiotensinconverting enzyme resulting
in decreased plasma
angiotensin II
concentrations; blood
pressure may be reduced in
part through decreased
vasoconstriction, increased
renin activity, and
decreased aldosterone
secretion. Also increased
renal blood flow. Pt has
hypertension.
Abdominal cramping, abd
distention, belching, flatulence,
dehydration, diarrhea,
excessive bowel activity,
hypernatremia, hypokalemia,
nausea, vomiting,
Teach pt of side effects of
drug, nausea, vomiting,
diarrhea, abd cramping, tell pt
to ambulate slowly and call for
assistance, monitor I &O’s,
assess bowel sounds, assess
abd pain and hydration, look
for s/s of hypokalemia and
hypernatremia and check
electrolytes.
Dizziness, cough, headache,
hyperkalemia, diarrhea,
hypotension, chest pain,
fatigue, nausea/vomiting, rash,
angioedema
Teach pt side effects of drug,
cough, hypotension,
angioedema, N/V, tell pt to rise
slowly and ambulate slowly,
monitor VS/BP, Maintain HOB
elevated, monitor for
hyperkalemia and s/s of
swelling. Hold medication if
BP low and notify MD.
Lorazepam (Ativan) –
Anticonvulsants,
Antianxiety agent,
Anxiolytics,
Benzodiazepines
1 mg IV PUSH Q6H
PRN
Sedative hypnotic with short
onset of effects and
relatively long half-life; by
increasing the action of
gamma-aminobutyric acid
(GABA), which is a major
inhibitory neurotransmitter
in the brain, lorazepam may
depress all levels of the
CNS, including limbic and
reticular formation. Pt
receiving medication PRN
for anxiety.
Magnesium Hydroxide
(Milk of Magnesia Susp) Laxative
30 ml PO x1 PRN
Laxative: Promotes osmotic
retention of fluid, which
distends the colon with
increased peristaltic activity
and stimulates bowel
evacuation.
Antacid: Reacts with
hydrochloric acid in
stomach to form the salt
magnesium chloride.
Miscellaneous Information
(Vancomycin Per Pharm)
Morphine Sulfate
(Morphine) – Opioid
Analgesic
1 each MISC PER
Parameter SCH
2 mg IV PUSH Q3H
PRN
N/A
Narcotic agonist-analgesic
of opiate receptors; inhibits
ascending pain pathways,
thus altering response to
pain; produces analgesia,
resp depression, and
sedation; suppresses cough
by acting centrally in
medulla. Pt receiving
morphine PRN for pain.
Sedation, dizziness,
weakness, unsteadiness,
fatigue, drowsiness, amnesia,
confusion, disorientation,
depression, vertigo, ataxia,
suicidal ideation, sleep apnea,
resp depression, tremor,
convulsion/deizures,
hypotension, nausea,
constipation, paradoxical
reactions (anxiety, excitation,
agitation, hostility, aggression,
rage), increased liver values,
jaundice, visual disturbances.
Hypotension, Resp
depression, diarrhea, abd
cramping, electrolyte
imbalance, muscle weakness.
N/A
Pruritus, urinary retention
vomiting, constipation,
headache, somnolence, abd
pain, diarrhea, dyspnea, fever,
nausea, insomnia, rash, resp
depression, anxiety,
orthostatic hypotension,
syncope, ileus, vertigo,
thinking disturbances.
Teach pt that this drug will only
be given in the even of an
anxiety attack and inform pt of
side effects of the drug.
Monitor pt for paradoxical
reactions, assess bowel
sounds, assess VS/BP, tell pt
to call for assistance for
ambulation, monitor pt
respirations closely, may need
to administer an antiemetic if
nausea persists and to prevent
vomiting with risk of aspiration.
Teach pt side effects of drug.
Assess pt’s need for the drug
by evaluating bowel habits.
Monitor serum magnesium for
signs of hypermangesemia,
such as bradycardia. Only
give as needed, monitor
VS/BP for signs of respiratory
depression and hypotension.
Inform pt to call for assistance
with ambulation due to
possible side effects of muscle
weakness.
N/A
Teach pt of side effects of
drug, perform a pain
assessment 1 hour prior to
and 30 mins following
administration, assess for s/s
of overdose (resp depression),
assess bowel function
routinely, increase fluid intake
to manage constipation,
assess VS/BP, tell pt to
ambulate slowly or call for
assistance and to report any of
the side effects immediately.
Multivitamins/Minerals
(Theragran M)-Vitamins
combination
Generic & Trade Name
Drug Classification
(Therapeutic &
Pharmacologic)
Nicotine (Nicoderm Cq) –
Smoking Cessation Aid
Nitroglycerin (Nitrostat) –
Nitrate, Angina
1 each PO DAILY
SCH
Vitamins help maintain
many different functions in
body, but unknown
mechanism of action. Pt
elderly with vitamin
deficiencies.
Upset stomach, unpleasant
taste, headache, vitamin
toxicity
Monitor pt nutrition intake and
for side effects of medication.
Teach pt side effects of
medication, and encourage
balanced diet with foods from
4 basic food groups.
Dose/Route
Frequency
Action of drug and Rationale
(Why is patient on
medication?)
Significant
Side Effects
(Serious and/or frequent)
Nursing implications related to
assessment, administration or
education
1 each
TRANSDERM
DAILY SCH
Transdermal nicotine
systematically absorbed;
binds to nicotine receptors;
reduces withdrawal
symptoms, including
nicotine craving, associated
with smoking cessation. Pt
uses tobacco.
Increased blood pressure,
tachycardia, dizziness,
insomnia, headache,
irritability, anorexia, diarrhea,
jaw/neck pain, nausea,
vomiting, cough, irritation at
application site, bronchitis,
indigestion, xerostomia, taste
disturbances.
0.4 mg SL Q5M
PRN
Organic nitrate which
causes venodilation,
decreasing preload.
Cellular mechanism: nitrate
enters vascular smooth
muscle and converted to
NO leading to activation of
cGMP an vasodilation.
Relaxes smooth muscle via
dose-dependent dilation of
arterial and venous beds to
reduce both preload and
afterload, and myocardial
O2 demand. Also improves
coronary collateral
circulation. Lower BP,
increased HR, occasional
paradoxical bradycardia. Pt
receives PRN for angina.
Headache, hypotension,
tachycardia, dizziness,
lightheadedness, blurred
vision, flushing, N/V,
nervousness, xerostomia,
syncope, thrombocytopenia,
prolonged bleeding time,
rebound hypertension.
Teach pt of side effects of
patch and importance of
continuing with the nicotine
patch therapy to help with
smoking cessation, and advise
pt to not smoke with the patch
on. Inspect site of
administration for a local
reaction (rash), tell pt that
exercise may increase
absorption, monitor VS/BP.
Teach pt of side effects of
drug, headache, dizziness,
N/V, and hypotension are all
common, teach pt that this is
only to be used if experiencing
symptoms of angina, teach pt
that this drug specifically
needs to be place under the
tongue, do not chew or
swallow. Assess location,
duration, intensity, and
precipitating factors of the
angina pain, monitor BP and
HR before and after
administration.
Ondansetron HCL (Zofran)
– Antiemetic & Serotonin 3
receptor antagonist
4 mg IV PUSH Q6H
PRN
Selective 5-HT3 receptor
antagonist; binds to 5-HT3
receptors in periphery and
CNS, primary effects in GI
tract. Pt postoperative and
on opioids PRN that might
cause nausea/vomiting
Headache, dizziness,
constipation, diarrhea,
dehydration, fatigue, dry
mouth, IV irritation
Pantoprazole Sodium
(Protonix) – Proton Pump
Inhibitor,
40 mg PO DAILY
SCH
Headache, abd pain, chest
pain, diarrhea, rash, pruritus,
flatulence, hyperglycemia,
nausea, angioedema,
pancreatitis, pancytopenia,
rhabdomyolysis, anaphylaxis.
Paroxetine HCL (Paxil) –
Antidepressant, SSRI
20 mg PO DAILY
SCH
PPI; binds to H+/K+
exchanging ATPase(proton
pump) in gastric parietal
cells, resulting in blockage
of acid secretion. Unsure
why pt is taking this
medication but indications
for medication are GERD,
esophagitis, peptic ulcer.
SSRI; little or no affinity for
alpha-adrenergic histamine
or cholinergic receptor. Pt
has depression.
Pravastatin Sodium
(Pravachol) – LipidLowering Agent, Statin,
HMG-CoA Reductase
Inhibitor
40 mg PO
BEDTIME SCH
HMG-CoA reductase
inhibitor, inhibits the ratelimiting step in cholesterol
biosynthesis by
competitively inhibiting
HMG-CoA reductase. Pt
has hyperlipidemia.
Somnolence, nausea,
insomnia, dry mouth,
headache, constipation,
asthenia, diarrhea, dizziness,
sweating, ejaculation disorder,
tremor, anxiety, blurred vision,
decreased appetite,
nervousness, hypotension,
tachycardia, tinnitus, vertigo,
depression exacerbation.
N/V, diarrhea, headache,
chest pain, fatigue, rash,
cough, heartburn
Teach pt side effects of
medication, teach pt to report
recurring nauseated feelings
and vomiting episodes, teach
pt to continue to elevate HOB.
Monitor pt for nausea &
vomiting, monitor I & Os,
assess bowel sounds, teach pt
side effects of drug, monitor
LOC, IV site, elevate HOB and
place emesis bin/basin next to
pt.
Teach pt side effects of drug
and to report any abd pain,
angioedema, anaphylaxis or
chest pain. Monitor pt I & O’s,
monitor pt BS and assess
bowel sounds.
Teach pt side effects of drug,
evaluate liver and renal
function tests prior to
administration, monitor for s/s
of depression, assess bowel
sounds, advise pt that this
should not be stopped
abruptly.
Teach pt side effects of drug
and to report cheat pain,
cough, N/V. Assess VS and
maintain HOB elevated, check
liver function tests prior to
starting drug.
Senna (Senokot) –
Laxative, Stimulant
8.6 mg PO x1 PRN
Intestinal irritant/stimulant.
Pt has had constipation.
Abd pain, diarrhea, excessive
bowel activity, melanosis coli,
nausea, electrolyte
abnormalities, yellow-brown
urine discoloration, nephritis
Sodium
Biphosphate/Sodium
Phosphate (Fleet Enema)
– Saline Laxative
133 ml PR x1 PRN
Draws water into the lumen
of the gut where it causes
osmotic effect; causes abd
distention and promotes
peristalsis and evacuation
of the bowel. Pt has had
constipation.
Replace Na and Cl, isotonic
solution. Pt only requiring
this to flush IVC to maintain
patency since pt in not on
IV Fluids.
Inhibits cell wall
biosynthesis; alters
membrane permeability and
RNA synthesis. Pt had a
surgical amputation.
Aspiration, dizziness,
headache, abd pain, N/V,
bloating, electrolyte
imbalance, facial edema,
cardiac arrhythmia, mucosal
bleeding, metabolic acidosis.
Sodium Chloride (Nacl
0.9% Flush) – mineral
electrolyte
Vancomycin HCL 1,000
mg in Sodium Chloride –
Glycopeptide, Antobiotic
10 ml IV PUSH Q8H
250 mls @ 166
mls/hr IVPB Q24H
SCH
Fluid overload, hypernatremia,
hyperchloermia.
Rash, hypotension, N/V,
stomatitis, Chills, drug fever,
nephrotoxicity,
thrombocytopenia, vasculitis,
ototoxicity.
Teach pt side effects of drug,
abd pain, excessive bowel
activity – may need to reduce
the dose. Monitor electrolytes
for abnormalities and monitor
for s/s of dehydration, monitor
I & O’s.
Teach pt side effects of drug,
tell pt to notify and side effects
immediately. Monitor
electrolytes, I & O’s, provide
assistance for ambulation,
monitor for facial edema and
assess HR.
Teach pt that this is only being
administered to maintain IVC
patency and that the listed
side effects are very minimal
to none.
Teach pt side effects of drug
and to report any side effects
immediately. Monitor
vancomycin serum levels prior
to administration, monitor renal
function tests, monitor I & O’s,
administer drug slowly to
decrease risk of adverse
effects, assess auditory
function, BP, perfusion
parameters and liver function
tests. Hold drug if vancomycin
levels elevated or increased
renal values.
Generic & Trade Name
Drug Classification
(Therapeutic &
Pharmacologic)
Vitamin B Complex
(Vitamin B Complex) – B
Vitamins, Water soluble
Vitamin
Dose/Route
Frequency
Action of drug and Rationale
(Why is patient on
medication?)
Significant
Side Effects
(Serious and/or frequent)
Nursing implications related to
assessment, administration or
education
1 each PO QDAY
SCH
Distribution to liver, bone
marrow, and other tissues.
Participates in physiologic
systems and reactions.
Unsure why pt is taking this
medication, possible
Vitamin B deficiency seen
on labs. Vitamins and
minerals.
Headache, dizziness,
arthralgia, naspharyngitis,
nausea, diarrhea, itching.
Teach pt side effects of drugs,
stress proper nutritional habits
to prevent recurrence of
deficiency. Provide assistance
with ambulation due to
possible dizziness.
Lab and Diagnostic Test Data
TEST
NORMAL VALUES
135-145
PATIENT
VALUES
(Day of Admission)
137
PATIENT
VALUES
(Recent Trends)
133
Na
K
3.3-5.0
5.1
4.9
C1
95-110
101
97
CO 2 (venous)
24-32
30
28
BUN
8-22
23
21
Creatinine
0.5-1.3
0.89
0.85
Greater than 60
Greater than 60
8.8
8.2
139
299
Blood glucose is not controlled, therefore there are varying
results during pt’s stay and attempting to control with
insulin
6.4
On the low end possibly due to pleural effusion
GFR
Ca
8.6-10.5
Ionized CA
1.20-1.32
Blood Glucose
70-110
Cholesterol
<200 mg
Triglycerides
35-160
Total Proteins
6.3-8.3
Amylase
56-190
Identify why this lab may be normal/abnormal related to
patients DX. Identify the purpose behind unusual labs
related to patient’s Dx. Identify trends (if any)
Value decreased during the stay, possibly due to D5W
administration or Lasix administration
Values decreasing possibly due to Lasix administration for
pleural effusion or pt was mildly dehydrated on admission
and is now becoming more hydrated, pt also taking ACE
inhibitors which elevate K levels
Normal but decreasing possibly due to the administration of
D5W and lasix
Decreasing possibly due to oxygen therapy and removal of
pleural effusion fluid
Values decreasing, pt possibly dehydrated and with
rehydration BUN is normalizing
Normal, but decrease in value suggests better renal
perfusion, hydration and Lasix administration
This indicates chronic kidney disease but unsure whether
stage 1 or 2, CKD probably due to uncontrolled diabetes.
Normal, decreasing trend, possible vit D deficiency, and
possible Lasix administration
TEST
NORMAL VALUES
PATIENT
VALUES
(Day of Admission)
PATIENT
VALUES
(Recent Trends)
Identify why this lab may be normal/abnormal related to
patients DX. Identify the purpose behind unusual labs
related to patient’s Dx. Identify trends (if any)
Lipase
0-110
Magnesium
1.2-2.0
Phosphorus
3.0-4.5
Troponin
<3.1
Myoglobin
0-85
Albumin
3.8-5.1
Alk. Phos.
20-180
GGT
0—65
T. Bili
.3-1.3
CPK (total)
0-250
CPK MB
<7.5
LDH
90-200
SGOT (AST)
8.42
SGPT (ALT)
10-60
WBC
4.5-11.0
18.6
10.3
13-16
9.1
8.2, 7.4, 9.7
Initial value indicated fairly severe infection, decrease in
value suggests that infection is under control and responding
to antibiotic therapy
Decreasing Hgb – anemia, possible due to recent surgery,
loss of blood and infection. Lab values reveal an expected
increase in Hgb post pRBC transfusion.
Hgb
TEST
NORMAL VALUES
37-49
PATIENT
VALUES
(Day of Admission)
27.9
PATIENT
VALUES
(Recent Trends)
25.4
Hct
RBC
4.5-5.3
3.42
3.1
PaO 2
80-100
% SAT
90-100
Ph
7.35-7.45
PaCO 2
35-45
HCO3
22-28
Platelets
130-400
540
500, 19, 59
INR
<1.16
PTT
23-33.5
URINALYSIS
2/24/14 urine culture
submitted, values
unknown
Color
Pale yellow
Clarity
Clear
Spec. Grav.
1.002-1.030
Identify why this lab may be normal/abnormal related to
patients DX. Identify the purpose behind unusual labs
related to patient’s Dx. Identify trends (if any)
Decrease possibly due to surgery, blood loss, fluid overload,
vitamin B deficiency, or CKD
Decrease possibly due to surgery, blood loss, fluid overload,
vitamin B deficiency, or CKD
Initial high values could have been due to CKD, infection, and
inflammatory process. Decrease value could have been due
to pt going into DIC with the severely ulcerative lesion on the
left limb or impaired platelet production, and surgery could
have contributed to the decrease. Increased to 59 post FFP
transfusions.
TEST
NORMAL VALUES
Occ. Blood
0
Ketones
0
Glucose
0
Albumin
0
PH
4.8-7.8
WBC/HPF
0-2
RBC/HPF
0-2
Bacteria/casts
0
X-RAY
CT SCAN
PATIENT
VALUES
(Day of Admission)
PATIENT
VALUES
(Recent Trends)
Identify why this lab may be normal/abnormal related to
patients DX. Identify the purpose behind unusual labs
related to patient’s Dx. Identify trends (if any)
2/27/14 right
thoracentesis
950mls submitted
fluid to cytology
Values unknown
LDH 430 (high)
TP 6.4 (low)
A high protein and high LDH shows that pleural effusion fluid
is local exudate rather then transudate or systemically
caused.
2/24/14
pleural effusion
2/24/14
pleural effusion
EKG
US
OTHER
2/24/14 blood cultures
submitted
2/25/14 Left
thoracentesis 900mls
Nursing Plan of Care
Chief Medical Diagnosis
Priority Assessments
Left great toe amputation due to PVD, Pleural Effusion, Uncontrolled DM
s/s infection, dressings (wound vac), VS, work of breathing, breath sounds, O2 sat, blood glucose monitoring
Nursing Diagnosis (Problems)
Data to Support
Planned Interventions
1) Problem #1 –Risk for infection
r/t surgical amputation of left
great toe as e/b wound vac
dressing and IV insertion
a) Wound vac on ulcerative lesion of
amputated toe
b) IV site left upper arm with NS 0.9% flush
and intermittent IV medications
c) pt Hx of DM
d) Pt limited to bed and minimal
ambulation within room
a) scheduled dressing changes twice
weekly for wound vac
b) scheduled IVC care site due today
c) continuing with insulin and
frequent FSBS checks and attempting
to regulate BS
d) plan to get pt up and ambulating
around the hospital
e) pt effectively able to move
remaining toes of left foot without
pain
Evaluation of Interventions
a) dressing looks clean
and dry on toe
amputation site
b) IVC site slightly red,
hard flush initially but
then worked fine
c) BS still unregulated
d) pt ambulating well
with walker
2) Problem #2 – Ineffective
breathing pattern r/t pleural
effusion as e/b SOB
3) Problem #3 – Ineffective
oxygenation r/t COPD as e/b
decreased SpO2 on room air
4) Problem #4 – Risk for fall r/t
left great toe amputation as e/b
a slower, more unstable gait
a) Thoracentesis on both right and left
sides 3 days apart, each about 900 mls
removed from each side
b) HOB elevated semi-fowler’s
c) Oxygen 2 LPM nasal prong
d) Xray revealed large amount of pleural
effusion prior to evacuation
a) Despite removal of pleural effusion
SpO2 remains decreased at 91-92% on
room air
b) Pt has an intermittent cough
c) Oxygen at 2LPM via nasal prongs
d) HOB elevated semi-fowler’s
a) Requiring the use of a walker for
ambulation
b) The great toe provides about 40% of the
foots support
a) thoracentesis right side removed
950 mls
a) post thoracentesis pt felt more
relieved and breathing is easier
a) Nebulize with albuterol
b) Maintain O2 at 2 LPM via nasal
prongs
a) pt breaths better with oxygen and
feels more comfortable
b) Unable t0 assess pt post
nebulization treatment
c) Resting comfortably
a) pt ambulates well with walker
b) Minimal to no pain per pt
a) Ambulated well around room
b) Able to get in and out of bed
c) Not present for ambulation
around hospital
5) Problem #5 – Risk for
ineffective peripheral tissue
perfusion r/t PVD as e/b
decreased blood flow to lower
extremities
6) Knowledge Deficit - Plan to
explain the importance of
exercise and diet. Plan to explain
the importance of smoking
cessation. Plan to explain the
importance of controlling DM and
controlling hypertension.
7) Discharge/Transfer - Pt must
be able to adequately
demonstrate FSBS and insulin
administration. Pt must be able
to demonstrate adequate foot
care. Pt should be able to explain
what an adequate diabetic diet is
composed of. Pt should be able
to demonstrate adequate use of
inhalers and have an
understanding of each mediation.
a) Absent dorsal pedal pulse in left foot
and faint in right foot
b) poeterior tibial pulse ¼ bilaterally
c) Decreased ABI in both limbs
d) Previous non-healing ulcers in both legs
e) PTA revealed severe blockage of major
vessels in both limbs
a) encourage frequent ambulation
b) encourage frequent ROM while
lying in bed
c) maintaining left limb elevated on
pillows
d) Monitoring and inspecting for any
signs of new ulcerations
.
a) pt is moving limbs frequently
(ROM) while in bed
b) ambulates well in room
c) no new ulcerative lesions noted on
lower extremities
d) limbs warm and equal to the touch
SBAR Pass Off Report
Situation
Background
Assessments
Recommendation
Patient B.D. is a 55 year old male, who presented to the hospital on 2/13/14 as ordered per his family practice physician because of
significant ischemic ulceration of the left lower leg. Pt has been non compliant with his diabetes, severe hyperglycemia, as well as the
treatment of the left leg wound and now pt condition is deteriorating. Pt complains of persistent pain, not feeling well for the past
month. Pt is febrile, very weak and possible risk of sepsis, severe COPD symptoms, Hypertension uncontrolled, dorsal pedal pulses absent
in left foot and unsure whether left limb is salvageable. During his stay on 2/24 pt developed a severe episode of SOB, almost requiring a
rapid response team, from labs, CT, and Xray a loarge amount of pleural effusion was noted, 2/25
Pt B.D. has been non-compliant with his diabetes and PVD. He has hx of CAD, hx of carotid vascular disease, previous intervention done
on both legs about 2 years ago. Pt continues to smoke, left carotid artery occlusion, multiple stents in coronary artery, carotid bilateral
bruits, uncontrolled severe COPD, normally functioning prosthetic aortic valve with no aortic insufficiency. Pt also has a previous history
of endocarditis and non-healing ulcers on both legs. Last ABI 0.8 Right leg, 0.9 left leg. Pt denies alcohol use and claims to get some
exercise.
During his stay on 2/14 pt had a PTA looking at the left leg. 2/16 left great toe amputation with debridement. 2/19 wound vac with
negative pressure therapy at 80 mmhg. 2/24 pt developed a severe episode of SOB, almost requiring a rapid response team, from labs,
CT, and Xray a large amount of pleural effusion was noted. 2/25 left thoracentesis 900mls removed. 2/27 right thoracentesis 950mls
yellowish colored fluid removed. Pt on vancomycin and Imipenem, last vancomycin levels elevated therefore one dose skipped.
Continues to receive Lasix for heart disease and pleural effusion, BNP on 2/25 was 813 indicating moderate heart failure. 2/26 Hgb 7.4
and platelets decreased to 19K, pt received 2 units pRBC’s, and 5 units FFP, Hgb increased to 9.7 and platelets increased to 59K. WBC at
9.1. Diabetes remains uncontrolled despite being on Humalog, Levemir and a diabetic diet. BP is better controlled, sepsis appears to be
resolved with improved WBC, and pain is minimal to none as recorded per patient. Pt remains on 2 LPM O2 via nasal prongs with SpO2 of
97-98%, SpO2 on room air post thoracentesis on 2/27 was 92% with minimal respiratory effort, pt said he did not feel difficult in breathing
but did appreciate a little oxygen. Overall pt is feeling better and in better spirits and says he is ready to go home.
Recommendations would include getting control of his diabetes with insulin and a proper diabetic diet, maintaining his BP, checking his
limbs everyday for any signs of lesions or ulcerations, smoking cessation, implementation of exercise to improve peripheral vascular flow
of blood to his extremities, further work up of pleural effusion and severity of heart disease as well as kidney disease.
Student Clinical Self-Appraisal
Weekly (turn in with Care Plan/Map)
Student _Erica Anacleto_________________
Course ADULT HEALTH II CLINICAL
Instructor AGNES ALICAR
Instructions: Please evaluate your performance during clinical today using the following concepts:
Patient Advocate
Critical Thinking
Self-Initiated
Safety
Leadership
Nursing Process
Professional Demeanor
Communication/rapport
Team Player
Organized
Well-prepared
Knowledgeable
Flexible
Peer Support
Skill Acquisition
Educator
Dependable
Areas of Strength Today (Date) 2/27/14
Areas Needing Growth-Include plan of improvement:
Team player – always willing to help teammates with their
pt
Organized – need to find more time to copy down
information and dates, need to learn better organization of
patient information, did not have all the information I
needed or wanted when writing this care plan, just not sure
where to begin when looking at the chart
Skill Acquisition - wanted to be more knowledgeable about
lung sounds and did not get the chance to auscultate
before and after thoracentesis
Peer support – able to help my classmates with some
charting definitions and able to explain some physiology,
procedures and equipment mechanics
Communication – I felt that I was able to adequately
communicate with the patient and build a rapport. We were
able to hold a conversation while I was obtaining vitals and
felt comfortable communicating with pt about his hobbies
Self-initiated – felt very insecure as to what my role was as
a student nurse, felt like I was in the way more than helpful,
would like to be able to jump in and feel comfortable with
just starting vitals, assessment, and bedside care
Nursing process – did not feel that I was following the
nursing process, felt very disorganized and unsure of my
place in the unit, might have been due to the confusion at
the beginning of the shift and the floor nurses not knowing
what we were capable of doing
Instructor Comments: