CSU, STANISLAUS B.S.N.
CLINICAL PLAN OF CARE
Student:
Erica Anacleto
Date of Care:
11/21/14
Room Number:
434-AICU
Patient Data
Admitting Diagnosis
Pneumonia
Age
58 years old
Spiritual Focus
Non specified
Culture
Non specified
Patient Initials
DW
Gender
Male
Height
185.4 cm
Weight
72 kg
Admitting Date
11/11/14
Vital Signs
T
96.9 F
P
79
R
20
B/P
127/60 (82)
O2Sat
98% on 0.50 mask
Pain Scale
0/10
Past Medical History
AIDS, HTN, BPH, Depression, Anemia of chronic disease, MRSA, Constipation, Abnormal gait, Seborrhea dermatitis
Surgical History
Laminectomy, Appendectomy
Diet:
Perative
Activity:
Bed rest, no ambulation at this time
Foley:
NG/Feeding Tube:
NG Tube Left Nare
Advance Directives:
Indwelling foley,
intact
Unknown
Code Status:
Full Code
VS Freq:
Q1hr
TEDs/SCDs:
SCDs continuous
Drains/
Tubes:
Glucose
Monitoring:
None
Q6hr FSBS
PCA/Epidural:
None
Telemetry:
Continuous, NSR
Vascular Access:
IV Site:
PICC line in left arm
IV Solution: None
Safety Considerations:
Fall Risk, PICC line right arm, NG tube left nare
Dressing Changes:
PICC line done today 11/21/14
Labs to be Drawn:
Drawn in the morning – CBC and Chemistry
Scheduled Procedures:
Pt taken off the ventilator and extubated
Notes on Pathophysiology:
Pt has AIDS and is non-compliant with medications, acquired pneumonia, culture positive for Pneumocystis
Pneumonia (PCP)
Lab and Diagnostic Test Data
Test type
(date)
Chem-7
Na
Normal
Range
Pt Results
Trends ↑
135-145
11/21/14
134

K
3.3-5.0
5

Cl
CO 2
Glucose
95-110
24-32
70-110
100
31
107, 111, 112
Slight 
Calcium
8.6-10.2
7.7

Rationale
(specific to pt)
Slight decrease in sodium could
possibly be to a lot of IV fluids prior to
them being D/C’d today.
Pt has a high normal value, borderline
hyperkalemia. Able to rule out kidney
failure because kidney values WNL. Pt
receiving potassium supplementation,
NG tube feeding may have potassium
as well, pt receiving heparin SC which
has been linked to hyperkalemia as
well as trimethoprim antibiotic.
WNL
WNL
Slight elevation not significant, pt is
not diabetic and is receiving NG Tube
feedings
Possibly decreased because pt had
received some magnesium sulfate at
one point
Nursing implications related to patient
care & teaching
Continue to monitor electrolytes, assess
VS, monitor I&O.
Continue to monitor Potassium level and
investigate the amount of potassium in
feedings. Continue to assess EKG noting
any changes. Make sure clinician is aware
of increase in Potassium.
Continue to monitor FSBS Q6hr as
ordered. Monitor for S&S of hypo or
hyperglycemia.
Teach pt about S&S of hypo or
hyperglycemia.
Monitor VS and maintain continuous EKG
and note any changes. Monitor for S&S of
hypocalcemia such as tetany and
hyperactive tendon reflexes. Continue to
monitor calicium levels at least daily.
Teach pt to report any feeling of tingling
or pins and needles around the mouth
and lips, in the extremeties of hands and
Test type
(date)
Normal
Range
Phosphorus
3.0-4.5
Pt Results
2.4
Trends ↑

Rationale
(specific to pt)
Nursing implications related to patient
care & teaching
feet. To report any signs of tetany.
The pt could possibly not be absorbing Continue to monitor phosphorus level.
phosphate due to malnutrition and
Provide phosphorus supplementation,
because although he has been
Assess NG Tube feeding and if pt is
receiving NG Tube feedings, he is
receiving his total nutrition requirement.
considered underweight and
Consider a nutrition consultation to assist
malnourished, so this may be an
the client in choosing the right foods and
ongoing problem.
maintaining a healthy diet.
Teach pt about the importance of
phosphorus and refer him to a dietician or
nutritionist.
Magnesium
Kidneys
1.2-2.0
BUN
Creatinine
GFR
Liver
8-22
0.5-1.3
>60
Total Protein
Albumin
6.1-7.9
3.8-5.1
Bilirubin Total
0.3-1.3
2.0
11/21/14
WNL
Kidney values are WNL despite the
slight decrease in creatinine.
15
0.49
>60
11/14//14
WNL
Slight decrease has no significance
WNL
Overall liver values are fairly normal,
no signs of liver damage, which can
occur when a pt is taking HIV/AIDS
meds.
WNL
This value was from 11/17, no other
value checked since then. Decrease
could be related to malnutrition. In
medical record documentation was
made that pt is malnourished.
6.6
1.3 on 11/17
0.2



Decreased bilirubin is not a concern
Continue to monitor Kidney values as
medications for HIV/AIDS have the
possibility of causing some renal problems
and also to assess pt hydration status
WNL
Continue to monitor liver lab values to
assess for any changes due to antivirals
for HIV/AIDS
It would be ideal to check another
albumin level and assess the trend.
Teaching the patient about proper
nutrition and refer him to a dietician or
nutritionist.
Test type
(date)
Alk phos
AST
ALT
Normal
Range
20-180
8-42
10-60
Cardiac
CPK
0-250
CPK-MB
<7.5
Troponin
0.01-0.06
Myoglobin
0-85
BNP
Blood
WBC
4.5-11.0
Pt Results
Trends ↑
51
35
No value
available
No value
available
No value
available
0.10 on
11/11/14
No value
available
No value
available
11/21/14
4.3
Rationale
(specific to pt)
Nursing implications related to patient
care & teaching
WNL
WNL


Increased troponin would generally
indicate that the pt had a heart attack,
but this pt has not had one. It is
possible that the troponin level is
increased due to the pt being in
severe respiratory distress.
Now that pt is off the ventilator able to
ventilate well and oxygenate well with
just nasal prongs, it would interesting to
check the troponin value again.
Although WBC level is still decreased
it is on an upward trend and
improving slowly. The decrease in
WBC is most likely due to the pt being
immunocompromised because of his
HIV/AIDS diagnosis and not being
compliant with medications.
Continue to check CBC daily checking for
improvement in WBC and assessing if the
pt’s H & H is maintaining and not
decreasing. Continue to protect pt from
infection by wearing gloves, gown and
mask.
Teach pt to report any chest pain and to
come in to doctor or hospital earlier when
he is having S&S of respiratory
complications.
Teach pt the importance of maintaining
compliance with HIV/AIDS medications
Test type
(date)
Hgb
Hct
RBC
Normal
Range
13-16
37-49
4.5-5.3
Pt Results
8.9
27.7
3.05
Trends ↑



Rationale
(specific to pt)
Still decreased but improving. Pt has
a history of anemia of chronic disease.
Pt received 2 units of pRBCs on 11/15.
Still decreased but improving. Pt has
a history of anemia of chronic disease.
Pt received 2 units of pRBCs on 11/15.
Still decreased but improving. Pt has
a history of anemia of chronic disease.
Pt received 2 units of pRBCs on 11/15.
Nursing implications related to patient
care & teaching
Continue to check CBC daily assessing if
the pt’s H & H is maintaining and not
decreasing. Continue to protect pt from
infection by wearing gloves, gown and
mask.
Teach pt the importance of maintaining
compliance with HIV/AIDS medications
and the possible need for another
transfusion
Continue to check CBC daily assessing if
the pt’s H & H is maintaining and not
decreasing. Continue to protect pt from
infection by wearing gloves, gown and
mask.
Teach pt the importance of maintaining
compliance with HIV/AIDS medications
and the possible need for another
transfusion
Continue to check CBC daily assessing if
the pt’s H & H is maintaining and not
decreasing. Continue to protect pt from
infection by wearing gloves, gown and
mask.
Teach pt the importance of maintaining
compliance with HIV/AIDS medications
and the possible need for another
transfusion
Platelets
INR
130-400
0.9-1.1
195
1.6 on 11/11/14

Only checked once on admit.
May be helpful to assess these values
Test type
(date)
PT
Normal
Range
10.4-12.8
PTT
Pt Results
19.0 on
11/11/14
Trends ↑

No value
available
No value
available
11/15/14 on 60%
FiO2 HFNC,
11/16/14 on
ventilator 50%
aPTT
Blood Gas
Rationale
(specific to pt)
Elevated lab value could be indicative
of low grade DIC, considering the pt’s
decrease in WBC and severe
pneumonia.
Only checked once on admit.
Elevated lab value could be indicative
of low grade DIC, considering the pt’s
decrease in WBC and severe
pneumonia.
Nursing implications related to patient
care & teaching
again to see if there is an improvement.
Monitor VS, S&S of bleeding and maintain
SCDs continuously and encourage
ambulation once ordered by the clinician
May be helpful to assess these values
again to see if there is an improvement.
Monitor VS, S&S of bleeding and maintain
SCDs continuously and encourage
ambulation once ordered by the clinician
ABGs improved with mechanical
ventilation. Values not checked again.
Might be helpful to obtain another ABG a
few days after being off the ventilator to
assess oxygenation and ventilation status
in comparison to original ABG at admit.
Teach pt the importance of taking
medications as ordered and prescribed in
order to avoid acquiring PCP again.
PaO 2
Sa O 2
Ph
PaCO 2
HCO3
URINALYSIS
80-100
90-100
7.35-7.45
35-45
22-28
Color
Pale
60.1, 107.1
90.9, 97.9
7.447, 7.394
28.8, 34.2
19.4, 20.4
11/11/14
Yellow





Only
checked on
admit and
WNL
Improved with mechanical ventilation
Improved with mechanical ventilation
Improved with mechanical ventilation
Improved with mechanical ventilation
Improved with mechanical ventilation
Urinalysis WNL and never rechecked
since admit.
It might be beneficial to check another
urinalysis since pt has had an indwelling
catheter for some time and the increasing
risk of infection due to his decreased WBC
and CAUTI.
Test type
(date)
Normal
Range
yellow
Clarity
Clear
Spec. Grav.
1.0021.030
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
Pt Results
Trends ↑
Rationale
(specific to pt)
Nursing implications related to patient
care & teaching
Clear
1.022
1
0
0
6.0
2
1
0/1
Chest, severe
infiltrates on
presentation
11/11. 11/20/14
much improved
CT SCAN
EKG
Continuous NSR
US
OTHER
None
None
Bronchoscopy
with cultures
submitted
PCP Positive
Radiographs Chest radiographs improving. This is
improving
due to the start of antibiotics and
maintaining the patient on the
ventilator for 5 days to allow the pt a
chance to rest from his increased
work of breathing.
Continue to check chest radiograph every
2-3 days to assess improvement and
continue to wean off oxygen. Assess
SpO2 values. Encourage ambulation once
ordered by doctor and encourage deep
breathing and coughing .
No changes
Maintaining continuous EKG to assess for
any S&S of distress while recovering from
being removed from the ventilator and
being extubated.
PCP positive result is related to the
patients history of HIV/AIDS and his
non-compliance with medications to
maintain his disease process.
Continue to monitor VS, SpO2. Possibly
implement incentive spirometry into pt
plan of care.
Teach pt the importance of compliance
with HIV/AIDS medications.
Medication Allergies:
Penicillin
Medications
Generic & Trade Name
Drug Classification
Dose/Route
Frequency
(Therapeutic &Pharmacologic)
Terazosin (Hytrin)autonomic nervous system
agent, alpha adrenergic
antagonist ,
antihypertensive
Sulfamethoxazoletrimethoprim (Bactrim,
Septra, C0-Trimoxazole) –
antiinfective, urinary tract
agent, sulfonamide
Ritonavir (Norvir) –
5mg PO bedtime
2000mg IVPB
250ml/hr in D5W
Q8hr over 2 hrs
100mg PO Q24
Action of drug and
Rationale
(specific to Pt)
Selectively blocks
alpha1-adrenergic
receptors in vascular
smooth muscle
producing relaxation that
leads to reduction of
peripheral vascular
resistance and lowered
BP – Pt HTN
Significant Side Effects
Nursing implications related to
patient care & teaching
Asthenia, dizziness,
headache, drowsiness,
postural hypotension,
syncope with first dose,
nausea, blurred vision,
peripheral edema, nasal
congestion and dyspnea.
Monitor for S&S of syncope, assess
BP prior to and after giving
medication, and again 2-3 hours
after medication was given.
Combination of an
intermediate acting
antiinfective
sulfonamide and
synthetic antiinfective.
Principal action if
enzyme inhibition, which
prevents bacterial
synthesis of essential
nucleic acids and
proteins. – Pt has
Pneumocystis carinii
pneumonitis.
Mild to moderate rashes,
toxic epidermal necrolysis,
nausea, vomiting, diarrhea,
anorexia,
pseudomembranous
enterocolitis, kidney failure,
agranulocytosis, aplastic
anemia, allergic myocarditis.
Monitor for S&S of allergic reaction
such as hives, itching, wheezing,
anaphylaxis. Check baseline labs.
Monitor coag times in patients
taking warfarin. Monitor I&O.
Monitor for overdose symptoms
such as nausea, vomiting, headache,
dizziness, mental depression,
confusion and bone marrow
depression.
HIV protease is an
Myalgia, asthenia, nausea,
Teach pt to make position changes
slowly, do not drive for at least 12
hours after first dose, check BP
regularly, do not take OTC meds
with an adrenergic blocker
Teach pt to repost any signs of
reaction. Monitor for fixed
eruptions. Drink 2-3 liters daily.
Periodically monitor CBC with
antiinfective, antiviral
agent, protease inhibitor
Potassium Chloride –
electrolyte and water
balance agent, replacement
solution
Scale for 60mEq,
40mEq, 20mEq PO
enzyme required to
produce the polyprotein
procurers of functional
proteins in infectious
HIV. Protease inhibitors
prevent cleavage of the
viral polyproteins,
resulting in the
formation of immature
noninfectious virus
particles. – Pt has AIDS
diarrhea, vomiting,
diabetes, insomnia, fatigue,
headache, confusion,
anxiety, vertigo, anemia, dry
mouth,, abnormal liver
function tests, rash,
urticarial, dry skin.
Principal intracellular
cation, essential for the
maintenance of
intracellular isotonicity,
transmission of nerve
impulses, contraction of
cardiac, skeletal, and
smooth muscles,
maintenance of normal
kidney function and for
enzyme activity. Plays
an important role in both
formation and correction
of imbalances in acidbase metabolism. – pt
Arrest, arrhythmias, cardiac
depression, respiratory
distress, flaccid paralysis,
nausea, vomiting, anuria,
hyperkalemia, hypotension,
bradycardia, ECG changes in
hyperkalemia, deterioration
of QRS contour and finally
ventricular fibrillation and
death.
differential and platelet count, liver
function, kidney function, serum
albumin, lipid profile, CPK, Serum
amylase, electrolytes, blood glucose
HbA1c and alkaline phosphatase.
Assess for S&S of GI distress,
peripheral neuropathy.
Teach pt to learn potential adverse
reactions and drug interactions and
to report to the physician any use of
OTC medications. Take the
medication exactly as prescribed, at
the same time each day and do not
skip doses.
Monitor I&O, if oliguria stop infusion
immediately, check frequent serum
electrolytes, monitor for GI
ulceration, monitor cardiac monitor
closely for any changes.
Teach pt to not be alarmed when
the tablet carcass appears in stools.
Learn about sources of potassium
with special reference to foods and
OTC drugs. Avoid licorice because
large amounts can cause both
hypokalemia and sodium retention.
Do not use any salt substitute. Do
not self prescribe laxatives. Call dr if
Nystatin (Mycostatin,
Nadostine, Nilstat) –
antiinfective, antifungal
antibiotic
5 ml PO Q6hr
Lorazepam (Ativan) –
central nervous system
agent, anxiolytic, sedativehypnotic, benzodiazepine
0.5 mg IV Q6 PRN
anxiety
getting supplemented as
needed according to
potassium lab value
scale.
Binds to sterols in fungal
cell membranes, thereby
changing membrane
potential and allowing
leakage of intracellular
components. – pt has
oral thrush (Candida
albicans)
Effects are mediated by
the inhibitory
neurotransmitter GABA.
Action sites: thalamic,
hypothalamic and limibic
levels of CNS
persistent vomiting, weakness,
fatigue, polyuria, polydipsia.
Nausea, vomiting, epigastric
distress, diarrhea
Monitor oral cavity, especially the
tongue for signs of improvement.
Teach pt that this drug can cause
contact dermatitis. Take after meals
and at bedtime. Dissolve troche in
mouth (about 30 mins), do not chew
or swallow, avoid food and drink
during period of dissolving and for
30 min after treatment.
Anterograde amnesia,
drowsiness, sedation, hyper
or hypotension, blurred
vision, nausea, vomiting,
anorexia, depression.
Have equipment for maintaining
patent airway immediately available.
Supervise ambulation of older adult
patients for at least 8 hours after
given. Supervise pt who exhibits
depression with anxiety closely.
Teach pt do not drive for at least 2448 h after receiving IM injection. No
not drink large volumes of caffeine.
Do not consume alcohol for at least
24-48h after receiving medication.
Terminate regimen gradually over a
period of several days. Do not self
medicate with OTC meds.
Insulin Regular (Humulin R,
Novolin R, Velodullin) –
hormone and synthetic
substitute, antidiabetic
agent, insulin
Heparin (Hepalean) – blood
formers, coagulators, and
anticoagulants,
anticoagulant
SC Q6hr PRN
sliding scale
5000u SC Q12
Enhances
transmembrane passage
of glucose across cell
membranes of most
body cells and by
unknown mechanism
may itself enter the cell
to activate selected
intermediary metabolic
processes. Promote
conversion of glucose to
glycogen. – Pt receiving
per hospital protocol
Exerts direct effect on
the cascade of blood
coagulation by
enhancing the inhibitory
actions of antithrombin
III on several factors
essential to normal
blood clotting, thereby
blocking the conversion
of prothrombin to
thrombin and fibrinogen
to fibrin.
Hypoglycemia, anaphylaxis,
hyperinsulinemia,
confusion, ataxia,
uncontrolled yawnsing,
hypothermia, Babinski
reflex, coma
Monitor for hypoglycemia, for
presence of acetone with sugar in
the urine (onset of ketoacidosis)
and/or acetone without sugar
(insufficient carbohydrate intake).
Monitor lab tests: periodic
postprandial glucose and HbA1c.
Test urine for ketones.
Teach pt correct injection technique
and inject onto abdomen rather
than a near muscle. Hypoglycemia
can result from excess insulin,
insufficient food intake, vomiting,
diarrhea, unaccustomed exercise,
infection, illness, nervous or
emotional tension or overindulgence
in alcohol. Carry some candy with
you at all times to treat
hypoglycemia. Be familiar with S&S
of ketoacidosis. Continue taking
insulin during an illness.
Spontaneous bleeding,
Monitor baseline blood coag tests
transient
such as hct, hgb, rbc, and platelet
thrombocytopenia, elevated counts prior to starting therapy and
BP, tingling of feet and
at regular intervals during therapy.
hands, bronchospasm,
Monitor APTT closely and does is
anaphylactoid reactions,
adjusted to maintain APTT between
suppressed renal function,
1.5-2.5 times normal control level.
hyperkalemia, injection site Monitor vital signs and observe al
reactions, pain, itching,
needle sites daily for hematoma and
ecchymoses, tissue irritation signs of inflammation. Make sure to
and sloughing
have protamine sulfate available as
antidote.
Glucagon (Glucagen) –
hormones and synthetic
substitutes
Fluoxetine Hydrochloride
(Prozac, Sarafem) – central
nervous system agent,
psychotherapeutic agent,
selective serotonin
reuptake inhibitor
1mg SC PRN
hypoglycemia and
no IV access
2mg via NGT daily
Inhibits formation of
new clots, high
molecular weight
polysaccharide with
rapid anticoagulant
effect, dose not lyse
existing thrombi but may
prevent their extension
and propagation. – Pt
non-ambulatory and has
been for entire hospital
stay due to being
sedated and ventilated
Polypeptide hormone
produced by alpha cells
of islets of Langerhans.
Stimulates uptake of
amino acids and their
conversion to glucose
precursors. Pt receiving
in the event of
hypoglycemia due to
receiving insulin
Antidepressant effect is
presumed to be linked to
its inhibition of CNS
neuronal uptake of
serotonin. Pt has a
history of depression
Nausea, vomiting, stevenjohnson syndrome,
hyperglycemia,
hypokalemia.
Headache, nervousness,
anxiety, insomnia,
drowsiness, fatigue, tremor,
hot flashes, nausea,
diarrhea, anorexia, blurred
vision, flu-like-syndorme.
Teach pt correct technique for
administrating heparin. Smoking
and alcohol consumption may alter
response to heparin and are not
advised. Do not take aspirin or any
other OTC meds without doctor
approval. Call dr if pink, red, dark
brown or cloudy urine. Call if
bleeding gums or oral mucosa,
ecchymoses, hematoma, epistaxsis,
bloody sputum, chest pain, severe
and continuous headache, dizziness.
Be prepared to give IV glucose if pt
does not respond to glucagon. Pt
usually awakens from diabetic
hypoglycemic coma 5-20 minutes
after glucagon given, give PO
carbohydrate ASAP after pt regains
consciousness.
Teach pt to have a responsible
family member taught how to
administer glucagon SC or IM.
Use with caution in the older adult
pt with impaired renal or hepatic
function, anorexic pt. Monitor
serum electrolytes. Monitor for S&S
of improved affect. Observe for
dizziness and drowsiness, increased
anxiety, nervousness or insomnia.
Supervise pt closely who is a high
suicide risk. Monitor hepatic and
renal impairment carefully for S&S
of toxicity.
Famotidine (Pepcid) –
gastrointestinal agent,
antisecretory agent (H2receptor antagonist.
20mg IV Q12
Emtricitabine + tenofovir
disoproxil fumarate
(Truvada) – HIV, ART
combos.
200mg-300mg 1
Tab via NGT
crushed daily
A potent competitive
inhibitor of histamine at
histamine H2 receptor
sites in gastric parietal
cells. Inhibits basal,
nocturnal, mealstimulated, and
pentagastrin-stimulated
gastric secretion, also
inhibits pepsin secretion.
– pt taking for increased
acid reflux
Dizziness, headache,
confusion, depression,
constipation, diarrhea, dry
skin, flushing,
thrombocytopenia,
increases in BUN and serum
Creatinine.
Emtricitabine is a
nucleoside reverse
transcriptase inhibitor,
following
phosphorylation
interferes with HIV viral
DNA polymerase and
inhibits viral replication.
Vomiting, diarrhea,
headache, dizziness, trouble
sleeping, back pain, change
in skin color on palms or
soles of feet.
Tenofovir is a nucleoside
reverse transcriptase
inhibitor , following
hydrolysis and
phosphorylation, inhibits
HIV-1 reverse
Teach pt to notify physician for any
S&S of a reaction. Monitor blood
glucose for loss of glycemic control if
diabetic.
Monitor for improvement of GI
distress, and for signs of GI bleeding.
Teach pt that pain relief may not
occur for several days after starting
therapy.
Monitor baseline and periodic renal
function. Monitor for S&S of bone
abnormalities. Monitor serum
creatinine and phosphorus.
Withhold medication if pt develops
lactic acidosis or pronounced
hepatotoxicity.
Teach pt to take medication exactly
as prescribed, do not miss any
doses. Report unexplained anorexia,
nausea, vomiting, abdominal pain,
fatigue, dark urine.
transcriptase by
competing with AMP as
substrate. - Pt has
HIV/AIDS
Dextrose 50% (D50W) Glucose elevating agent
Darunavir (Prezista) – HIV
protease inhibitors
25 gram IV Q5min
for severe
hypoglycemia, 25
gram IV Q15min
PRN for FSBS less
than 60
Parenteral dextrose is
oxidized to carbon
dioxide and water, and
provides 3.4 cal/gram of
d-glucose. Pt on
medication PRN for
hypoglycemia. Pt taking
in the event of
hypoglycemia.
Hyperosmolarity,
hypervolemia, phlebitis,
pulmonary edema, cerebral
hemorrhage, cerebral
ischemia, hyperglycemia,
injection site extravasation.
Monitor for hyperglycemia, check
blood glucose frequently after
administering.
800mg via NGT
crushed daily
bedtime
Protease inhibitor,
inhibits cleavage of GagPol polyprotein
precursors, which in turn
causes the formation of
immature, noninfectious
viral particles. Pt has
HIV/AIDS
Increased total cholesterol,
increased triglycerrides,
diarrhea, headache, rash,
abdominal pain, nausea,
vomiting, anorexia.
Monitor liver function before and
during therapy. Use with caution in
patients with known sulfonamide
allergy. Pt may develop new onset
diabetes mellitus or hyperglycemia.
Codeine is a narcotic
agonist analgesic with
antitussive activity, mu
receptor agonist
Drowsiness, constipation,
bradycardia, hypotension,
tachycardia, confusion,
dizziness, weakness,
urticarial, anorexia, nausea,
vomiting, dyspnea,
headache.
Codeine+guaifenesin –
10ml via NGT Q8
(Mytussin AC) - Antitussives,
narcotic combos
Guaifenesin reduces
viscosity of secretions by
increasing amount of
respiratory tract fluid.
Pt most likely taking
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 to learn drug interactions
and to avoid taking with other meds.
Pt should call in the event of an
adverse reaction.
Monitor for nervousness and
anxiety. Assist with ambulation.
Monitor renal values. Check VS
often to monitor for hypotension
Teach pt to move slowly and no
sudden position changes. Do not
drive and do not exceed the
recommended dosage. Discontinue
if cough persists for greater than 1
week and call dr. Do not use this if
Chlorhexidine (Peridex,
PerioGard) – Antibiotics,
oral rinse.
Aripiprazole (Abilify) - CNS
agent, psychotherapeutic,
antipsychotic, atypical
Alprazolam (Xanax) –
central nervous system
agent, anxiolytic, sedativehypnotic, benzodiazepine
while on the ventilator
and may be continuing
to assist with persistent
cough.
15ml rinse mucous Polybiguanide antiseptic
membranes Q12
and antimicrobial drug
with bactericidal activity,
binds to the negatively
charged bacterial cell
walls and extramicrobial
complexes. Pt has oral
thrush and has been on a
ventilator and unable to
clean his own oral cavity.
5mg via NGT daily Exhibits high affinity for
Dopamine and serotonin
receptors, functions as a
partial agonist at the
Dopamine D2 and the
serotonin 5H1A
receptors, and as an
agonist at
serotonin5HT2A
receptors. Mechanism of
action unknown, but
actions at other receptors
may explain side effects
such as orthostatic
hypotension. Pt taking
for depression.
0.5mg via NGT Q6 Binds receptors at
several sites within the
PRN anxiety
CNS, including the limbic
system and reticular
formation. Pt on
medication for anxiety.
you have chronic pulmonary disease.
Increased tartar on teeth,
skin and oral irritation,
staining of tooth, bronchitis,
taste sense altered,
toothache, dry mouth,
gingivitis, anaphylaxsis.
Inform pt that reduced taste
perception is reversible with the
discontinuation of product.
Headache, anxiety,
insomnia, lightheadedness,
somnolence, akathisia,
tremor, extrapyramidal
symptoms, nausea,
vomiting, hypotension,
confusion, hypertension,
tachy/bradycardia, weight
gain or weight loss.
Monitor vital signs, HR, BP, Temp.
Monitor for S&S of tardive
dyskinesia
Monitor for S&S of neuroleptic
malignant syndrome
Monitor Hct and Hgb and glucose
Monitor ambulation for risk of fall
Drowsiness, depression,
headache, constipation,
diarrhea, dry mouth,
tachycardia, confusion,
insomnia, nausea/vomiting,
hypotension, blurred vision,
Monitor for S&S of drowsiness and
sedation, pt may require supervised
ambulation. Monitor periodic blood
counts, urinalysis and blood
chemistry during continued therapy.
Teach pt to not swallow the rinse.
Teach pt to carefully monitor blood
glucose levels if diabetic, do not
drive, avoid situations where you are
likely to become overheated or
dehydrated.
Albuterol ipratropium
(DuoNed, Combivent
Respimat) – Respiratory
Inhalant Combos
Acetaminophen (Tylenol) Analgesic, Antipyretic &
nonopioid analgesic
3ml neb Q4 or Q2
for SOB
650mg via NGT Q4
PRN Temp greater
than 101 F
Ipratropium is an
anticholinergic agent
that inhibits vagally
mediated reflexes by
antagonizing
acetylcholine action,
prevents increase in
intracellular calcium
concentration caused by
interaction of
acetylcholine with
muscarinic receptors on
bronchial smooth
muscle.
Albuterol is a beta2adrenergic
bronchodilator.
Pt taking for
bronchospasms.
It is an analgesic and an
antipyretic. It acts on the
hypothalamus to produce
syncope, nervousness,
tremor, nasal congestion
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
Bronchitis, upper
respiratory tract infection,
lung disease, headache,
dyspnea, cough, chest pain,
nausea, diarrhea, dry
mouth, hypertension,
palpitation, nervousness,
tachycardia, tremor.
Monitor respiratory status,
auscultate lungs before and after
administering. Report treatment
failure. Monitor for tremors and
tachycardia. Monitor SpO2
frequently if not continuously.
Angioedema, dizziness,
steven-johnson syndrome,
urticarial, GI hemorrhage,
Monitor for S&S of hepatotoxicity.
Teach pt this medication is not for
emergency use. Rinse mouth after
treatment. Avoid contact with eyes.
Dizziness and vertigo can occur
therefore careful ambulation.
Teach pt to not exceed 4 grams/day.
antipyresis and may work
peripherally to block pain
impulse generation. Pt
taking PRN for fever
AcetaminophenHydrocodone 325mg-5mg
(Norco) - Analgesic,
antipyretic, antiflammatory
& opioid analgesic combo
Ondansetron HCL (Zofran)
– gastrointestinal agent,
antiemtic, 5-HT3
anatagonist
1 tab via NGT Q4
PRN moderate
pain (4-7)
8mg IV Q4 PRN
nausea
Hydrocodone binds to
carious opioid receptors
producing analgesia and
sedation, acetaminophen
exact mechanism of
action unknown. Pt
taking PRN for pain.
hepatotoxicity, rash,
disorientation, neutropenia,
leukopenia,
thrombocytopenia,
pancytopenia.
Drowsiness, constipation,
nausea, respiratory
depression, lightheadedness, sedation, dry
mouth, vomiting.
Selective serotonin
Dizziness, lightheadedness,
receptor antagonist,
headache, sedation, diarrhea,
serotonin receptors are
constipation, dry mouth
located centrally in the
chemoreceptor trigger
zone and peripherally on
the vagal nerve stimulus,
serotonin is released
from the wall of the
small intestine and
stimulates the vagal
efferents through the
serotonin receptors and
initiates the vomiting
reflex. Pt taking PRN for
nausea.
Take with food.
Monitor for any S & S of
anyphylaxis and steven-johnson
syndrome.
Monitor for effectiveness of pain
relief, for nausea, vomiting,
respiratory status and bowel
elimination. Monitor pt ambulation
Teach pt to not exceed 4 g in 24 hrs
of Tylenol from all sources. Do not
drive. Drink plenty of fluid. Do not
use alcohol and take as prescribed.
Monitor fluid and electrolyte status.
Monitor for effectiveness and for
decreased S&S of nausea and
vomiting
Teach pt that headaches are common
and may require analgesic relief/
Admitting Diagnosis: Pneumonia
Priority Assessments: Work of breathing, airway, breath sounds, VS, SpO2, PICC line dressing
Nursing Dx 1: Ineffective breathing r/t pneumocystis pneumonia as e/b sob without oxygen and cough
 SpO2 87% on room air
 Pt struggles to cough
 Pt coughing up thick, sticky sputum and requiring suctioning often
 Respiratory rate 50 bpm
 50% FiO2 via mask
 HOB elevated semi-Fowler’s and Fowler’s
NIC
NOC
1. Provided percussion at pt request
1. Pt tolerated percussion well and was able to
2. Assessed pt and obtained vital signs
have a more productive cough
3. Assisted pt with oral suctioning of sputum
2. Ronchi present bilaterally, SpO2 95% with 50%
4. Replaced mask on pt and explained
FiO2 mask on properly, Temp 96.9, HR 89, RR
importance of maintaining the mask
20-30, BP 127/60 (82), pain 0/10
5. RT consult approximately 2 hours after being
3. Secretions were thick, tan and sticky
taken off the ventilator
4. SpO2 decreased to 87-89% on room air
6. Assisted in turning pt
5. RT discontinued the nebulization oxygen mask
and place the patient on nasal prongs at 50%
FiO2, pt more comfortable
6. Pt had some discomfort when turning but
ultimately felt better
Nursing Dx 2: Acute confusion r/t pt sedated and ventilated for the past 5 days and just weaned off today as e/b pt unsure of where he is at and
why he is there.
 Pt stated that he was in a plane crash
 Pt couldn’t remember where the nurse call button was
 Pt unable to recall why he called for the nurse
NIC
NOC
1. When pt unable to recall why he called me
1. Pt appreciated the patience and time to reinto his room, I allowed him time to think
orient himself and he was eventually able to
about it and did other things in his room or
recall why he called me into his room
went to get him some cool wash cloths
2. I assured him that the nurse call button is right
next to him and to push the big red button
when he needs something
3. Able to reorient pt back to the present time
and remind him where he is at, what
happened and that his confusion is normal
2. He felt more comfortable knowing that the
call button was on his lap
3. Pt was easily re-oriented when kept in
conversation, but would quickly forget once I
left the room
Nursing Dx 3: Risk for infection r/t pt immunocompromised as e/b pt history of HIV/AIDS
 Decreased WBC
 PICC line in right arm
 Indwelling foley
 Weaned off ventilator today and extubated
 Pt non-compliant with HIV/AIDS medications as noted in his chart and evident by his CD4 count
NIC
NOC
1. Gave the pt a bed bath, new bedding, new
1. Pt felt much better after bed bath and fresh
gown, cleaned foley well
linens
2. Performed PICC line care and applied new
2. PICC insertion site clean, not red, line remains
dressing
patent and no oozing from insertion site when
3. Encouraged pt to take deep breaths and cough
flushed
4. Obtained FSBS – 112 mg/dL
3. Difficult for pt to take deep breaths, but was
able to cough effectively and produce some
secretions
4. FSBS WNL. Good indicator that the pt is still
tolerating the NG Tube feeding well
Nursing Dx 4: Risk for aspiration r/t NGTube feedings
 Continuous NG Tube feeding @ 60 mL/hr
 Pt stating the need to vomit
 Pt taken off ventilator and sedation today
NIC
1. Maintained HOB in semi-Fowler’s and Fowler’s
2. Assessed bowel sounds
3. Residuals checked by nurse
NOC
1. Pt tolerated semi-Fowler’s better than
Fowler’s position
2. Bowel sounds present in all 4 quadrants and
no pain on palpation
3. Residuals less than 60 mls
Nursing Dx 5: Nausea as e/b pt stating he has severe nausea and appears distressed
 Pt stating he is going to vomit
 Appears very uncomfortable
 Pt receiving medications that could be causing the nausea
 Pt just weaned from sedation
NIC
NOC
1. Provide pt with an emesis pan and placed HOB
1. Pt tolerated Fowler’s position and was able to
in Fowler’s position
hold the emesis pan on his own
2. Assessed pt pain level
2. Pt declared he had no pain, just severe nausea
3. Assessed medications pt receiving
3. Pt receiving Sulfamethoxazole + Trimethoprim
4. Notified charge nurse of pt nausea
and infusion just completed about 1 hour ago.
5. Provided pt with cool wash cloths on chest
This medication can cause nausea, but many
and forhead
of his medications have the common side
6. Administered 4 mg Zofran
effect of nausea
7. Assessed pt about 45 minutes later
4. Charge nurse called the clinician and received
8. Provided distraction for pt
an order for Zofran 4 mg IV Q4 PRN nausea
5. Pt stated that the cool wash cloths felt good
6. Pt tolerated the administration of Zofran
7. Pt still nauseous 45 minutes after Zofran
administration
8. Spoke with pt about his career as a NICU nurse
and a RT, this provided some distraction and
he was able to talk about his experiences as
well as laugh a little
NURS 4810
Plan of Care Evaluation
Student Name: Erica Anacleto
Date: 11/21/14
Week#:2
Faculty: Jo Sokolo
Instructions: Attach a copy of this form to each of you Clinical Plan of Care/Maps for grading purposes.
1. Patient Data includes: (10 pts.)
_________/10
a.
Physical data
b.
Health history
c.
Interventions as ordered
2. Each medication includes (10 pts.)
_________/10
a.
Name (Trade & Generic)
b.
Rationale
c.
Side effects
d.
Nursing Implications
3. Laboratory Data (10 pts.)
_________/10
a.
Patient Values and Trends
b.
Etiology & Implications for the patient
4. Concept Map includes all appropriate physiologic, psychologic or social problems, discharge planning & pt.
education (20pts):
_________/20
5. Each problem includes (20 pts):
_________/20
a. Nursing diagnosis
b. Data to support
c. Appropriate interventions
6. Critical Assessments are appropriate to diagnosis (10pts)
_________/10
7. Evaluation of Interventions includes (10 pts):
_________/10
a. Physical interventions
b. Psychosocial interventions
c. Patient education
8. Appearance of Overall Care Map (10 pts)
_________/10
Total:
Comments:
__________%