NURSING 111 CARE PREPARATION
Student Name: Stephanie Perkins
Unit/Room Number: PSU 377
Age: 81
Gender: Male
Erikson’s Developmental Level: Integrity vs Despair
Date of Care: 2/12/15
Date of Admission: 2/11/15
Ethnic/Cultural Preferences: White
Allergies: NKA
Code Status: DNR
Primary Diagnosis: Acute respiratory failure
Co-morbidities: Hx of CVA, dyspnea, COPD pneumonia
Discharge Plan (add day of clinical):
Integrated Pathophysiology (what is going on with your patient at the cellular level for the health condition, no more than
three pages in length, including reference page)
Fluid builds up in the alveoli sacs of the lungs which then causes a decrease of oxygen in the blood as
evidenced by dyspnea. COPD correlates with this as it’s a chronic condition of fluid in the lungs which also
causes dyspnea.
Data Collection (Record exactly what is written on the personal information sheet [aka Kardex]. Any assessment/elaboration
should be made on the assessment sheet):
Diet (Type): Regular, vegetarian, mechanical soft
I&O (MD order/Nursing Order/Frequency): no
Fall Risk/Safety Precautions (Yes/No):
Wound Care (Yes/No):
Drains (Yes/No, Type):
Other Tubes:
IV (Fluid type, rate, access type): FS Sodium Chloride 0.9%
999 mL/hour over 1 H stat
CBG (Yes/No, frequency): no
Activity (What is ordered): Up for meals, up ad lib
minimum 4 times daily
Oxygen (Yes/No, Delivery method, how much): Yes 2-4
L/min NC
Last BM: will assess day of clinical
ASSESSMENTS
(Include Subjective & Objective Data)
Integumentary:
Color appropriate for race, c/d/I, turgor present no
wounds or lesions.
Head and Neck:
Normocephalic, nontender
Ear/Nose/Throat:
No drainage, nares patent, oral mucosa pink and
intact. Mouth and tongue dry.
Thorax/Lungs:
Expiratory and inspiratory wheezes and rhonchi
throughout lower lobes
Cardiac:
S1S2 heard but diminished. PP weak and easily
obstructed no edema cap refill less than 3 sec
Musculoskeletal: Grips equal bilaterally extremities
strength equal bilaterally
Genitourinary:
Urine yellow no sediment or odor output 75 cc
Gastrointestinal:
Abdomen soft and nontender bowel sounds
hypoactive in all 4Q
Neurological: A/O x 3 PERRLA
Other (Include vital signs, weight): BP 128/60 P 87 O2
100 Pain 0/10 RR 20
CURRENT MEDICATIONS
List ALL regularly scheduled and prn medications scheduled on your client.
(Due morning of clinical)
Generic & Trade
Name
Classification
Dose/Route/
Rate if IV
Onset/Peak
Intended
Action/Therapeutic use.
Why is this client taking
med?
Adverse reactions (1
major side effect)
Nursing Implications for this client. (No more than
one)
Saline Flush
(Sodium
Chloride
Flush)
0600
Albuterol/Ip
ratrop
(Duoneb)
0800 1200
Aspirin EC
(Acetylsalicy
lic Acid)
0900
Calcium
Carb/Vit D
(Caltrate/
Vit D)
0900
Chlorhexidi
ne (Peridex)
0900
Enoxaparin
(Levenox)
0900
Mupirocin
(Bactroban)
0900
Paroxetine
(Paxil)
0900
Maintenan
ce Fluid
10 ml
n/a
IV patency
Irritation
Assess IV site
Bronchodil
ator
3 ml neb
QID
5-15
min/0.5-2h
Decrease airway
resistance
Worsening of
breathing
problems
CPV assessment before and after
treatment to determine effectiveness
Nonnarcot
ic
Analgesic
81 mg 1 tab
PO daily
Unknown/1
5 min-2 h
Pain relief of low to
moderate intensity
Thrombocytope
nia
Assess labs
Fluid and
electrolyte
replaceme
nt solution
1 tab PO
daily
Unknown/u
nknown
Calcium
supplement
Constipation
Abdominal Assessment
Germicidal 0.12% oral
mouthwas rinse 15 ml
h
mucosal BID
Anticoagul 40 mg=0.4
ant
ml SC daily
Unknown/u
nknown
Reduces bacteria in
mouth
Assess oral mucosa
Unknown/
3h
Antithrombotic
agent
Severe irritation
and chemical
burns
hemorrhage
Antibiotic
Not
systemically
absorbed
2 wk/ 5-8 h
Rid of nasal
bacteria
Burning
Assess for burning
Treat depression
Worsening
depression
Assess efficacy
2%
Ointment
Nasal BID
Antidepres
20 mg= 1
sant
tab PO Daily
Assess labs
Prenatal
Vitamin w/
Iron
0900
Vitamin D
2000 unit
0900
Acetaminop
hen
(Tylenol)
Albuterol
HFA
(Ventolin
HFA)
Albuterol
neb sol
(Ventolin
Proventil)
Nicotine
Transderma
l patch
Ondansetro
n (Zofran
INJ)
multivitam
in
1 mg PO
daily-meal
Vitamin
deficiency/supplem
ent
constipation
Vitamin
2 tab PO
daily
Helps to absorb
calcium and
phosphorus
Relieve pain
none
Nonnarcot
ic
Analgesic
2 tab PO
q4h prn
minor
pain/HA
Bronchodil 2 puff q 4 h
ator
prn
wheezing/
SOB
Bronchodil
3 ml neb
ator
q2h prn SOB
5-15
min/0.5-2h
Smoking
deterrent
Antiemetic
1 patch prn
nicotine
cravings
2 ml IV q4h
prn nausea
vomiting
Unknown/
0.5-2 h
Assess abdomen
Acute renal
failure in acute
poisoning
Assess labs
Decrease airway
resistance
Worsening of
breathing
problems
CPV assessment before and after
treatment to determine effectiveness
5-15
min/0.5-2h
Decrease airway
resistance
Worsening of
breathing
problems
CPV assessment before and after
treatment to determine effectiveness
Unknown/
8-9 h
Reduce withdrawal
symptoms of
smoking
Prevents n/v
Localized edema
Skin assessment
Diarrhea
Assess stools
Unknonw/
1-1.5 h
DIAGNOSTIC TESTING
Include pertinent labs [ABGs, INRs, cultures, etc] & other diagnostic reports [X-rays, CT, MRI, U/S, etc.]
NOTE: Adult values indicated. If client is newborn or elder, normal value range may be different.
Date
2/11
Lab Test
Normal Values
Patient Values/
Date of care
Sodium
135 – 145 mEq/L
Potassium
3.5 – 5.0 mEq/L
Chloride
97-107 mEq/L
Co2
23-29 mEq/L
Glucose
75 – 110 mg/dL
BUN
8-21 mg/dL
140
Creatinine
0.5 – 1.2 mg/dL
Uric Acid Plasma
4.4-7.6 mg/dL
Calcium
8.2-10.2 mg/dL
Phosphorus
2.5-4.5 mg/dL
Total Bilirubin
0.3-1.2 mg/dL
Total Protein
6.0-8.0 gm/dL
Albumin
3.4-4.8gm/dL
Cholesterol
<200-240 mg/dL
Alk Phos
25-142 IU/L
SGOT or AST
10 – 48 IU/L
LDH
70-185 IU/L
CPK
38-174 IU/L
WBC
4.5 – 11.0
RBC
1.73
male: 4.7-5.14 x 10
female: 4.2-4.87 x 10
HGB
male: 12.6-17.4 g/dL
female: 11.7-16.1 g/dL
HCT
male: 43-49%
female: 38-44%
MCV
85-95 fL
MCH
28 – 32 Pg
MCHC
33-35 g/dL
RDW
11.6-14.8%
Platelet
150-450
Interpretation as related to Pathophysiology –cite
reference & pg #
4.7
108
Renal failure not being able to excrete chloride
24
97
32
Renal failure not being able to excrete waste
product
Severe renal impairment
n/a
9.2
n/a
0.6
8.3
dehydration
3.7
n/a
97
26
n/a
n/a
9.8
3.82
Hemolytic anemia
11.6
Hemolytic anemia
35.2
Decrease in number or RBC
92
30.4
33.0
14.2
189
DIAGNOSTIC TESTING
Date
UA
Normal
Range
Results
Interpretation as related to
Pathophysiology –cite reference & pg #
Results
Interpretation as related to
Pathophysiology –cite reference & pg #
Color/Appearance
pH
Spec Gravity
Protein
Glucose
Ketones
Blood
Date
Other
(PT, PTT, INR, ABG’s,
Cultures, etc)
Normal
Range
++++++
Date
Radiology
X-Rays
Scans
EKG-12 lead
Telemetry
Results
Interpretation as related to
Pathophysiology –cite reference & pg #
DAR NURSING PROGRESS NOTE
Include the same note that was written in the client record for the priority nursing diagnostic statement.
Include the date/time/signature.
2/12/15 1230
Patient up in wheelchair. Lung sounds diminished, inspiratory and expiratory wheezing. Rhonchi and crackles
present. Assisted in ordering lunch and in feeding. During feeding pt coughed after every bite. Inquired about
denture use and pt stated “they’re too expensive”. Called for speech therapy consult for a swallow study
which lead to diet change of mechanical soft and thick liquids with thin liquids between meals. Left pt with call
light in reach, brakes on, O2 at 3 L-------------------------------------------------------------------------Stephanie Perkins SN
PATIENT CARE PLAN
Patient Information:
Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as evidenced by (AEB).
Problem #1 Impaired gas exchange r/t lung disease AEB dyspnea
Desired Outcome: Patient will not experience s/s of dyspnea at rest during shift
Nursing Interventions
Client Response to Intervention
1. Assess CVP q 2 h
1. Inspiratory and Expiratory wheezing and
rhonchi with crackles
2. Encourage use of incentive spirometer q1h
2. Able to get to 750
3. Educate proper use of inhalers every
administration
3. n/a RT did all nebulizer treatments
Evaluation (evaluate goal & interventions, what worked/what didn’t, what would you adapt if needed): This pts lung sounds
were absolutely horrendous. He was able to use the incentive spirometer a few times and I educated him on how to use it
correctly. I did leave it on the bedside table as well to serve as a visual reminder. I think these interventions worked well minus
the inhaler/neb treatments since RT did all of those. I hope that throughout his stay the other RNs and CNAs do similar
interventions to help him get better.
Problem #2 Risk for Aspiration r/t swallowing difficulties AEB coughing during meal time.
Desired Outcome: Patient will not show s/s of aspiration during meal time (i.e. coughing, gagging, etc.)
Nursing Interventions
Client Response to Intervention
1. Assess lungs before and after meal time
1. Lung sounds unchanged before and after
meal, however lots of food in back of throat
after swallowing
2. Assess for s/s of aspiration during meal time
2. Coughed during and after mealtime
3. Consult for swallowing evaluation
3. Diet was changed to mechanical soft and
thickened liquids with thin liquids between
meals
Evaluation (evaluate goal & interventions, what worked/what didn’t, what would you adapt if needed): Assessing the lungs
before meals helped establish a baseline so if there was an aspiration I had something to look back on. He
did cough during the mealtime so that’s why I had speech therapy evaluate his swallowing. During the
evaluation it was discovered that he’s a silent aspirator so his diet was changed to prevent aspiration
pneumonia. In all I think these interventions worked well to help him in the future.
Problem #3 Activity intolerance r/t lung disease AEB dyspnea
Desired Outcome: Patient will walk at least 50 feet 4 times during shift
Nursing Interventions
Client Response to Intervention
1. Assess extent to which pt is able to move around
1. Pt weak, able to transfer from bed to
in room at beginning of shift
wheelchair with 1 person assist
2. Encourage patient to walk 50 feet 4 times during
shift
3. Educate patient about controlled breathing during
activity
2. Unable to walk d/t weakness
3. O2 stats raised during deep breathing
exercises
Evaluation (evaluate goal & interventions, what worked/what didn’t, what would you adapt if needed): Besides the walking
the other interventions worked. This pt had tried to adjust himself in bed and in doing so his O2 stats
dropped significantly from 92 to 85. The deep breathing exercises helped bring his O2 stats back up to 92.