PATIENT DATA PACKET - Elevated troponin nursing care plan

PATIENT DATA PACKET

NURS 113-114

Important: Absolutely no patient identifiers from the medical record may be used on this data packet (HIPAA).

|Student Name: |Clinical Week (1,2,3,4,5): |

|Instructor Name: |Unit: |

|CLIENT PROFILE |

|Age |♀ ♂ |CODE STATUS |HT |Admit WT |Current WT |

|Allergies |

|Admit VS |Admit S/S |

|Admit Diagnosis |

|Medical History/Other Medical Diagnoses |

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|Current Surgery (Post-Op Day) |

|Activity Level |Diet |I/O: yes no |

|IV (site; solution & rate) |Pain Management: |

|Support Tubes (type) |

|Therapy &/or Treatments |

|Social Support System |

|ANTICIPATED NURSING CARE PLAN |

|List 2 anticipated Nursing Diagnoses: |

|ANTICIPATED PRIORITY FOCUSED ASSESSMENT |ANTICIPATED PRIORITY NURSING DIAGNOSIS |ANTICIPATED NURSING INTERVENTIONS |

| | |3 Minimum: Only 1 can be r/t assessment or |

|*Include rationale for why this is a |*Include rationale for why you chose this as the highest |monitoring) |

|priority |priority nursing diagnosis |*Include rationale for interventions |

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| |EXPECTED OUTCOME: | |

PATIENT DATA PACKET

|PATHOPHYSIOLOGY |

|Primary (Admitting) Diagnosis or Current Problems: |

|Textbook Etiology: |

|Client Specific Etiology: |

|Pathogenesis |

|Textbook Signs & Symptoms: |

|Patient S/S related to primary admitting diagnosis or current problem: |

|Integrate pertinent client/patient medical history (with instructor guidance): |

|Source of Pathophysiology (textbook and page number): |

PATIENT DATA PACKET

|MEDICATIONS - SCHEDULED |

|(Highlight any medications that were discontinued prior to giving.) |

|*Must cite references of resources utilized: |

|Generic & Trade Name |Dose |Route |Time |Classification |Nursing Implications |Evaluation of Medication Effects |

| | | | |& |(What do you need to know or do to give this medication safely?) | |

| | | | |Action | | |

| | | | |Therapeutic class |Patient specific medical reason for taking medication (For what specific patient |What would you assess to know the med is |

| | | | |Pharmacologic class |condition was this medication ordered? Condition should be evident in diagnosis,|working? |

| | | | |Action of med |history, pathophysiology &/or labs.) |What were the results of your assessment? |

| | | | | |Medication Allergeis | |

| | | | | |Pertinent side effects | |

| | | | | |Pertinent Labs & Assessment Data | |

| | | | | |Implementation: Pertinent considerations for safe & effective administration | |

| | | | | |Client/Family Teaching | |

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PATIENT DATA PACKET

|MEDICATIONS – PRN |

|(List only those given in the last 24 hours. Highlight any medications that were discontinued prior to giving.) |

|*Must cite references of resources utilized: |

|Generic & Trade Name |Dose |Route |Time |Classification |Nursing Implications |Evaluation of Medication Effects |

| | | | |& |(What do you need to know or do to give this medication safely?) | |

| | | | |Action | | |

| | | | |Therapeutic class |Patient specific medical reason for taking medication (For what specific |What would you assess to know the med is |

| | | | |Pharmacologic class |patient condition was this medication ordered? Condition should be evident |working? |

| | | | |Action of med |in diagnosis, history, pathophysiology &/or labs.) |What were the results of your assessment? |

| | | | | |Medication Allergeis | |

| | | | | |Pertinent side effects | |

| | | | | |Pertinent Labs & Assessment Data | |

| | | | | |Implementation: Pertinent considerations for safe & effective administration| |

| | | | | |Client/Family Teaching | |

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PATIENT DATA PACKET

|LAB VALUES |

|Lab Test |Normal |Lab |Rationale |Assessment Findings |

|(PERTINENT TO PATIENT CONDITION, |Range |Values w/ Dates |Identify pertinent labs (even if normal) |(Based on the lab result, what would you expect |

|PATHO & MEDS) | | |If lab is abnormal, explain why; if normal, explain why pertinent. |to see in your assessment?) |

|CBC | | | | | |

|Hemoglobin (Hgb) |12-18 | | | | |

|Hematocrit (Hct) |38-54% | | | | |

|Platelet Count |150-400 | | | | |

|White Blood Cell (WBC) |4-11 | | | | |

|Differential Neutrophils | | | | | |

|- Segs |50-70% | | | | |

|- Bands |0-8% | | | | |

|Lymphocytes |20-40% | | | | |

|Monocytes |4-8% | | | | |

|Eosinophils |0-4% | | | | |

|Basophils |0-2% | | | | |

|RBC Indices | | | | | |

|MCH (Mean Corpuscular Hemoglobin) |27-33 pg | | | | |

|MCHC (Mean Corpuscular Hemoglobin |32-36% | | | | |

|Concentration) | | | | | |

|RDW (Red Blood Cell Distribution) |11-14.5% | | | | |

| |variation | | | | |

PATIENT DATA PACKET

|LAB VALUES (Continued) |

|Lab Test |Normal |Lab |Rationale |Assessment Findings |

|(PERTINENT TO PATIENT CONDITION, |Range |Values w/ Dates |Identify pertinent labs (even if normal) |(Based on the lab result, what would you expect |

|PATHO & MEDS) | | |If lab is abnormal, explain why; if normal, explain why pertinent. |to see in your assessment?) |

|ELECTROLYTES | | | | | |

|Chloride |95-105 | | | | |

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|Potassium |3.5-5 | | | | |

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|CO2 |20-30 | | | | |

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|Calcium |9-11 | | | | |

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|Anion Gap |6-17 | | | | |

|(Na + K) – (Cl + Bicarb) | | | | | |

|RENAL | | | | | |

|Creatinine |0.5-1.5 | | | | |

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|BUN/ Creatinine Ratio |12-20 | | | | |

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|GFR |>60 | | | | |

PATIENT DATA PACKET

|LAB VALUES (Continued) |

|Lab Test |Normal |Lab |Rationale |Assessment Findings |

|(PERTINENT TO PATIENT CONDITION, PATHO|Range |Values w/ Dates |Identify pertinent labs (even if normal) |(Based on the lab result, what would you expect |

|& MEDS) | | |If lab is abnormal, explain why; if normal, explain why pertinent. |to see in your assessment?) |

|LIVER | | | | | |

|Aspartate Aminotransferase (AST) |10-40 | | | | |

|Alanine Aminotransferase (ALT) |4-36 | | | | |

|Total Bilirubin |0.2-1.3 | | | | |

|Amylase |0-130 | | | | |

|Lipase |0-160 | | | | |

|Total Protein |6-8 | | | | |

|Albumin |3.5-5 | | | | |

|CARDIAC | | | | | |

|Troponin – I | | | | | |

|BNP |< 100 pg/ml | | | | |

|Total Cholesterol |140-200 mg/dl | | | | |

|LDL | 55 mg/dl | | | | |

| |♂ > 45 | | | | |

| |mg/dl | | | | |

|Triglycerides |40-190 mg/dl | | | | |

PATIENT DATA PACKET

|LAB VALUES (Continued) |

|Lab Test |Normal |Lab |Rationale |Assessment Findings |

|(PERTINENT TO PATIENT CONDITION, PATHO|Range |Values w/ Dates |Identify pertinent labs (even if normal) |(Based on the lab result, what would you expect |

|& MEDS) | | |If lab is abnormal, explain why; if normal, explain why pertinent. |to see in your assessment?) |

|MISCELLANEOUS | | | | | |

|Hgb A1C |< 7 | | | | |

|PTT |30-45 seconds *| | |*Therapeutic is 1.5-2.5 times the control | |

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|PT |12-15 seconds* | | |*Therapeutic is 1.5-2 times the control | |

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|INR (International Normalized Ratio) |2-3* | | |* Desired ranges are different depending on indication. | |

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|Stool Guiac |Neg | | | | |

|OTHER LABS: For example: Culture, | | | | | |

|Gram Stain, & Sensitivity (Blood, | | | | | |

|Urine, Sputum; ABGs; etc.) | | | | | |

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Labs are divided into specific sections, but keep in mind that labs can be abnormal due to other problems. For instance, an ALP can be elevated due to bone abnormalities

not just liver problems.

Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O’Brien, P., & Bucher, L. (2007). Medical-surgical nursing: Assessment and management of clinical problems. Mosby/Elsevier

Pagana, K.D. & Pagana, T.J. (2006). Mosby’s manual of diagnostic and laboratory tests. St. Louis, MI: Mosby/Elsevier.

PATIENT DATA PACKET

|LAB VALUES (Continued) |

|Lab Test |Normal |Lab |Rationale |Assessment Findings |

|(PERTINENT TO PATIENT |Range |Values w/ Dates |Identify pertinent labs (even if normal) |(Based on the lab result, what would you expect |

|CONDITION, PATHO & MEDS) | | |If lab is abnormal, explain why; if normal, explain why pertinent. |to see in your assessment?) |

|Urinalysis | | | | | |

|Specific Gravity |1.003-1.030 | | | | |

|pH |4 - 8 | | | | |

|Protein |Negative | | | | |

|Blood |Negative | | | | |

|Bilirubin |Negative | | | | |

|Glucose |Negative | | | | |

|Ketones |Negative | | | | |

|Nitrites |Negative | | | | |

|Leukocyte Esterase |Negative | | | | |

|Microscopic: | | | | | |

|RBCs |Few to none | | | | |

|Bacteria |Negative | | | | |

|Casts |Negative | | | | |

|Crystals |Negative | | | | |

|Yeast |Negative | | | | |

|Epithelials |Negative on a good | | | | |

| |sample | | | | |

PATIENT DATA PACKET

|DIAGNOSTIC TESTS |

|(Examples: X-Ray, MRI, CT, ECG |

|Date |Diagnostic Test |Results |Nursing Implications |

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Physical Assessment

(HIGHLIGHT abnormal data or defining characteristics for problems)

| |CHANGES FROM DAY #1 |

|Day One |Day Two |

|General Survey |General Survey |

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|Vital Signs Time |Time |Vital Signs Time |Time |

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|Pain: Rating |Description |Pain: Rating |Description |

|Pain: Rating |Description |Pain: Rating |Description |

|Pulse Oximetry |Oxygen |Pulse Oximetry |Oxygen |

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|Neurological/ Psychological |Neurological/Psychological |

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| EEN/ Mouth | EEN/ Mouth |

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|Cardiovascular |Cardiovascular |

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|Respiratory |Respiratory |

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|Gastrointestinal/GU |Gastrointestinal/GU |

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|Musculoskeletal |Musculoskeletal |

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|Integumentary |Integumentary |

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|Lines/Tubes/Dressings |Lines/Tubes/Dressings |

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Functional Health Patterns (Gordon’s)

(HIGHLIGHT abnormal data/defining characteristics for problems)

|Health Perception-Health Maintenance Pattern |Cognitive – Perceptual Pattern |

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|Activity – Exercise Pattern |Coping – Stress Tolerance |

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|Nutrition– Metabolic Pattern |Self Perception – Self Concept Pattern |

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|% of diet eaten: | |

|Fluid intake ml | |

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|Elimination Pattern |Role – Relationship Pattern |

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|Sleep – Rest Pattern |Value – Belief Pattern |

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Refer to page 233 of your Fundamentals of Nursing textbook by Potter & Perry.

Draft Documentation

(For student use only – do not turn into instructor.)

|Date/Hour |Nursing Progress Note |

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Documentation

|Date/Hour |Nursing Progress Note |

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Nursing Plan of Care

|NURSING DIAGNOSIS |

| Two part diagnostic statement with R/T (1 point) |

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| Defining Characteristics “as evidenced by” (1 point) |

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| #1 priority because: (1 point) |

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|EXPECTED OUTCOME (Must be measureable with time frame) (1 point) |

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|NURSING INTERVENTIONS (1.5 points) |RATIONALES (1.5 points) |

|(3 required-only 1 may be assessment) | |

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|EVALUATION OF EXPECTED OUTCOME (1 point) |

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|SUGGESTED MODIFICATIONS (1 point) |

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Nursing Plan of Care

|NURSING DIAGNOSIS |

| Two part diagnostic statement with R/T (1 point) |

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| Defining Characteristics “as evidenced by” (1 point) |

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| #2 priority because: (1 point) |

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|EXPECTED OUTCOME (Must be measureable with time frame) (1 point) |

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|NURSING INTERVENTIONS (1.5 points) |RATIONALES (1.5 points) |

|(3 required-only 1 may be assessment) | |

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|EVALUATION OF EXPECTED OUTCOME (1 point) |

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|SUGGESTED MODIFICATIONS (1 point) |

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