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CSU, STANISLAUS B.S.N.CLINICAL PLAN OF CAREStudent:Sara HannahDate of Care:12/9-12/10Room Number: 13Patient DataAdmitting DiagnosisAcute Cardiopulmonary arrest, pneumothoraxAge67Spiritual FocusCatholicCultureHispanicPatient InitialsYFGenderFemaleHeight5’4”Weight134 lbsAdmitting Date 12/4Vital SignsTPRB/PO2SatPain Scale37.79529118/6692%N/A37.98918103/51100%N/A37.57818111/55100%N/APast Medical HistoryNIDDM, C. Diff, CVA, SepsisSurgical HistorynoneDiet:NPOActivity:BedrestFoley:YesNG/Feeding Tube:NoDrains/ Tubes:Left chest tubeETT #7.5Advance Directives:YesCode Status:12/9 Full Code12/10 DNRGlucose Monitoring:Q2 hrs, cover Q4VS Freq:Q1HTEDs/SCDs:YesPCA/Epidural:NoTelemetry:YesVascular Access:IV Site:#20 R AC TLC L FemIV Solution:D5? NS with KSafety Considerations:Contact isolation Hx C. Diff, aspiration precautions, bleeding precautions, stage 11 ulcer, glucose monitoringDressing Changes:12/9- stage II ulcer to coccyx dressing change, 12/10- stage II ulcer to coccyx dressing changeLabs to be Drawn:For 12/10- CBC, CMP, cardiac panelScheduled Procedures:12/9- EEG to be done; 12/10- EEG showed no substantial brain activityDiagnoses after admission:Acute Hypoxic respiratory failure 2/2 fluid overload, aspiration pneumonia, sepsis with high lactate 2/2 UTI, DKANotes on Pathophysiology:Cardiopulmonary arrest: a sudden stop in effective blood circulation due to failure of the heart to contract effectively or at all. Arrested blood circulation prevents delivery of oxygen and glucose to the body. Lack of oxygen and glucose to the brain causes loss of consciousness, which then results in abnormal or absent breathing. Brain injury is likely to happen if cardiac arrest goes untreated for more than five minutes. For the best chance of survival and neurological recovery, immediate and decisive treatment is necessary.Acute Hypoxic respiratory failure: Acute hypoxemic respiratory failure (AHRF) is severe arterial hypoxemia that is refractory to supplemental O2. It is caused by intrapulmonary shunting of blood resulting from airspace filling or collapse. Findings include dyspnea and tachypnea. Diagnosis is by ABGs and chest x-ray. Treatment usually requires mechanical ventilation.Aspiration Pneumonia: Tiny particles from the mouth frequently dribble or are inhaled (aspirated) into the airways. Usually they are cleared out by normal defense mechanisms (such as coughing) before they can get into the lungs and cause inflammation or infection. When such particles are not cleared (because of impaired defense mechanisms or because the volume of aspirated material is so large), they can cause aspiration pneumonia. Older people and people who are debilitated, have trouble swallowing (as may happen from a stroke), are intoxicated by alcohol or drugs, or are unconscious from anesthesia or a medical condition are especially at risk for this type of pneumonia. Symptoms of pneumonia do not begin for at least a day or two. The sputum may smell foul. Treatment requires antibiotics. Lab and Diagnostic Test DataTest type(date)Normal RangePt Results12/9-12/10Trends ↑Rationale(specific to pt)Nursing implications related to patient care & teachingChem-7Na135-145nLK3.3-5.0nLCl95-110nLCO 2 24-3220, 17downFound with DKA, metabolic acidosis; ketoacidosis and other ions are built up, HCO3- neutralizes these acids therefore being used up and levels drop-Drugs that may cause decreased levels include methicillin, nitrofurantoin, paraldehyde, phenformin, tetracycline, thiazide diuretics and triamtereneGlucose70-110176, 70Towards nLWithout taking prescribed insulin, plasma glucose has built up since the glucose cannot enter the cells-Administer insulin-Finger stick every 2 hours-Use sliding scale for dosingCalcium8.6-10.27.1, 7.3Towards nLhigh pH in the blood that drives the calcium to intracellular spaces causing blood levels to decline-Assess for renal failure-Monitor PTH; if levels are low, Ca tends to be low as wellPhosphorus3.0-4.5nLMagnesium1.2-2.0nLKidneysBUN8-22nLCreatinine0.5-1.3nLGFR>60LiverTotal ProteinAlbumin3.8-5.12.2, 2.0SameCan be caused by malnutrition (low protein levels). Most likely the liver disfunction (albumin synthesis) associated with malnutrition also contributes to low level. Protein can also be lost when patient was experienced repeated hematemesis and diarrhea as was seen in recent hospital stay-Measurement of hepatic function-Maintains colloidal osmotic pressure-Helps transfer drugs, hormones, enzymes-Factor in that with low albumin, drugs administered may not be getting to full efficacyBilirubin Total0.3-1.3nLAlk phos20-180nLAST8-42ALT10-60CardiacCPK0-250nLCPK-MB<7.5nLTroponin <3.1Myoglobin 0-85BNPBloodWBC4.5-11.017.8, 15.8Towards nLSignifies infection or inflammation or tissue necrosis or stress on the body especially related to sepsis diagnosis-Administer daily antibiotics as ordered-Monitor visitors and initiate appropriate ppd precautions -Monitor vitals, especially temperature Q1HHgb13-169.2, 9.2 sameCould be caused by expanded blood volume related to IV fluid delivery. Could be caused also by UGIB and the loss of blood through hematemesis (seen upon recent hospital stay). Possible iron deficiency-Rapid indirect measurement of RBCs-Monitor kidney function since erythropoietin is a strong stimulant to RBC production and is made in the kidneysHct37-4928.1, 27.9same(See above)(See above)RBC4.5-5.3Platelets130-400INRPTPTTaPTTBlood GasPaO 280-100Sa O 290-100pH7.35-7.457.55Alkalosis (patient was in metabolic acidosis upon arrival but that has been corrected at this time)Place on versed for anesthetic effects to regulate breathingPaCO 235-4527.1Respiratory (alkalosis); patient was trying to outbreath her ventilation which was causing excess CO2 leaving bodySee aboveHCO322-2827.6nL(was high upon admission with acidosis suggesting metabolic in nature)URINALYSISColorPale yellowClarityClearSpec. Grav.1.002-1.030Occ. Blood0Ketones0Glucose0Albumin0PH4.8-7.8WBC/HPF0-2RBC/HPF0-2Bacteria/casts0X-RAYCXR+ for infiltrates to right mid and left lower lobes. Suggests possible aspiration-At risk patient-Treat with antibiotics-Sputum may be odorousCT SCANnegativeNo acute brain bleedContinue to monitorEKGSinus rhythmNo acute MIContinue to monitorEEGNo brain activityAnoxic brain injuryInitiate palliative care Medication Allergies:NKDAMedicationsGeneric & Trade Name Drug Classification(Therapeutic &Pharmacologic)Dose/Route FrequencyAction of drug and Rationale(specific to Pt)Significant Side EffectsNursing implications related to patient care & teachingMidalozam HydrochlorideVersedAnesthetic adjunct, benzodiazepine (short or intermediate acting)50 mg/50 ml IV For this patient, versed was implemented to the plan of care when the patient was “overbreathing” her ventilator. This was shown respiratory alkalosis found by ABGs. Given Versed as anesthetic to prevent overbreathing and decreased respiratory rate.May cause excessive somnolence, HA, hiccoughs, apnea, desaturation of blood, CNS depression, respiratory depression-Monitor respiratory and cardiac condition continually including direct visual observation -Monitor respiratory rate and oxygen saturation in hemodynamically compromised patients receiving continuous infusionInsulinAnti-hyperglycemicSliding scaleFor this patient, it is being used to regain plasma blood glucose control and reduce ketoacidosis. Hypoglycemia, weight gain, edema, heart failure, hypokalemia, anaphylaxisUse sliding scale to monitor the patients glucose levels. Take finger sticks per protocol and adjust dosing. Protocol in this case was finger sticks Q2H and cover with sliding scale Q4H to avoid overcorrectingNorepinephrineLevophedvasopressor0-20 mcg/min; titrate to maintain MAP >65 IVFor this patient, levophed was given to increase MAP which was low upon presentation for this patient. Works by peripheral vasoconstriction and coronary artery vasodilation. Helps maintain heart function.Cardiac arrest, dysrhythmias, hypertension, nausea, vomiting, headache, confusion, urinary retention-Instruct patient to report signs of extravasation and instruct to report common side effects. -Monitor blood pressures closely Q2H after desire blood pressure has been established-Will cause cool extremitiesPhenytoin Dilantinanticonvulsant150 mg IV Q8HFor this patient, in the morning of 12/8, she was seen to be having twitching and jerking movements of face and arms. Placed on a Dilantin drip which is a anticonvulsant to decrease what was thought to be seizure activity.May cause dizziness, somnolence, confusion, nystagmus, paresthesia, HA, ataxia, decreased coordination, insomnia, slurred speech, nausea, vomiting, edema-Drug may exacerbate diabetic conditions, blood glucose should be closely monitored. -Patient should avoid activities that require mental alertness or coordination until drug effects are realizedVancomycinAntibioticTricyclic glycopeptide 1 g/250 ml Q12HIVGiven for this patient as treatment for aspiration pneumonia. Also UA showed positive for infection in the urine. Given for infection. It inhibits bacterial wall synthesis; also alters the permeability of bacterial cell membrane and interferes with RNA synthesis. Works against gram + microorganisms and is synergistic when combined with other antibiotics.Erythroderma, nausea, vomiting, hypokalemia, abdominal pain, diarrhea, hypotension, agranulocytosis, neutropenia, thrombocytopenia, ototoxicity, nephrotoxicity-Get blood cultures and CBC with differential to determine if needed. -Symptomatic improvement, including resolution of fever is indicative of efficacy-Serum through levels should be above 10 mg/L in adults to prevent resistance-Obtain trough levels just before fourth dose and repeat as clinically necessary-Monitor renal function, high risk of nephrotoxicity-Monitor for ototoxicity6485255-4038603.) Diagnosis: Risk for imbalanced nutrition: more than body requirements related to high blood glucose levels as evidenced by: - altered mental status PTA -HA1c 14.4-Lethargy PTA-Blood glucose levels 271 upon arrival-ABGs showed metabolic acidosis upon arrival to ED-Per family, patient was not taking diabetic control medications while in rehabilitation facility following recent hospitalization-Long history of poor diabetic control and poor dietary nutritionExpected Outcome/Goals:-Blood glucose levels will be maintained within normal range by using Q2H finger sticks and covering with a sliding scale of IV insulin Q4H.-Ketoacidosis will be resolved-Patient will be started on palliative care regimen-The attending physician will implement palliative care including diabetic control measures as they see necessary-Comfort care003.) Diagnosis: Risk for imbalanced nutrition: more than body requirements related to high blood glucose levels as evidenced by: - altered mental status PTA -HA1c 14.4-Lethargy PTA-Blood glucose levels 271 upon arrival-ABGs showed metabolic acidosis upon arrival to ED-Per family, patient was not taking diabetic control medications while in rehabilitation facility following recent hospitalization-Long history of poor diabetic control and poor dietary nutritionExpected Outcome/Goals:-Blood glucose levels will be maintained within normal range by using Q2H finger sticks and covering with a sliding scale of IV insulin Q4H.-Ketoacidosis will be resolved-Patient will be started on palliative care regimen-The attending physician will implement palliative care including diabetic control measures as they see necessary-Comfort care-228600-4038601.) Diagnosis: Risk for deep vein thrombosis related to venous stasis associated with decreased mobility and increased blood viscosity if fluid intake is inadequate as evidenced by:-Increased time spent supine, no physical activity, no responses to stimuli of any kind-Hx MI-Comatose, intubation, non-ambulatory Interventions: Reposition client avoiding positions that compromise blood flow elevate foot of bed for 20-minute intervals several times a shiftSCDsmaintain a minimum fluid intake of 2500 ml/day unless contraindicated to prevent increased blood viscosityadminister anticoagulants (e.g. low- or adjusted-dose heparin, warfarin, low-molecular-weight heparin) if orderedExpected Outcome/Goals:The client will not develop a deep vein thrombus as evidenced by:absence of pain, tenderness, swelling, and distended superficial vessels in extremitiesusual temperature of extremitiesnegative Homans' sign.001.) Diagnosis: Risk for deep vein thrombosis related to venous stasis associated with decreased mobility and increased blood viscosity if fluid intake is inadequate as evidenced by:-Increased time spent supine, no physical activity, no responses to stimuli of any kind-Hx MI-Comatose, intubation, non-ambulatory Interventions: Reposition client avoiding positions that compromise blood flow elevate foot of bed for 20-minute intervals several times a shiftSCDsmaintain a minimum fluid intake of 2500 ml/day unless contraindicated to prevent increased blood viscosityadminister anticoagulants (e.g. low- or adjusted-dose heparin, warfarin, low-molecular-weight heparin) if orderedExpected Outcome/Goals:The client will not develop a deep vein thrombus as evidenced by:absence of pain, tenderness, swelling, and distended superficial vessels in extremitiesusual temperature of extremitiesnegative Homans' sign.3361055-4038602.) Diagnosis: Risk for ventilator acquired pneumonia related to ventilation as evidenced by:-Lack of deep inspiration and coughing-Pt has no gag reflex, is not protecting airway-Pt is on ventilation, comatose-Pt has audible secretions in bibasilar lung fields upon auscultation-Is in dependent supine position with limited movement-Recent intubation prior to admission plus prolonged time spent intubated during this hospital stayExpected Outcome/Goals:-Treat with antibiotics, goal to reduce inf.-Manage fever if present with suppository Tylenol-Suction ETT Q1H -Maintain adequate oral care while avoiding signs of skin breakdown002.) Diagnosis: Risk for ventilator acquired pneumonia related to ventilation as evidenced by:-Lack of deep inspiration and coughing-Pt has no gag reflex, is not protecting airway-Pt is on ventilation, comatose-Pt has audible secretions in bibasilar lung fields upon auscultation-Is in dependent supine position with limited movement-Recent intubation prior to admission plus prolonged time spent intubated during this hospital stayExpected Outcome/Goals:-Treat with antibiotics, goal to reduce inf.-Manage fever if present with suppository Tylenol-Suction ETT Q1H -Maintain adequate oral care while avoiding signs of skin breakdown30480002381256248400123825003124200219075Admitting Diagnosis: Acute cardiopulmonary arrest, pneumothoraxSecondary Diagnoses: Acute Hypoxic respiratory failure 2/2 fluid overload, aspiration pneumonia, sepsis 2/2 UTI, DKA00Admitting Diagnosis: Acute cardiopulmonary arrest, pneumothoraxSecondary Diagnoses: Acute Hypoxic respiratory failure 2/2 fluid overload, aspiration pneumonia, sepsis 2/2 UTI, DKA46482001047750-2286002362204.) Diagnosis: Ineffective family coping related to brain death as evidenced by:- family disagreeing on DNR and process of taking patient off ventilation; Spouse expresses still thinking that despite EEG readings showing no brain activity, the patient will be waking up-Spouse states that the patient woke up last time she was in ICU and he thinks she will this time too-Cousins and other family members agree with the doctor and support the DNR but spouse not ready to remove intubationExpected Outcome/Goals: -Spouse will voice understanding of what EEG outcomes mean; he will have adequate time to accept and prepare for palliative measures -Specifics of palliative measure will be discussed with the healthcare provider and family in detail and put into action-Family will be provided with appropriate time and conditions to cope with death; patient will pass with maximal comfort and dignity004.) Diagnosis: Ineffective family coping related to brain death as evidenced by:- family disagreeing on DNR and process of taking patient off ventilation; Spouse expresses still thinking that despite EEG readings showing no brain activity, the patient will be waking up-Spouse states that the patient woke up last time she was in ICU and he thinks she will this time too-Cousins and other family members agree with the doctor and support the DNR but spouse not ready to remove intubationExpected Outcome/Goals: -Spouse will voice understanding of what EEG outcomes mean; he will have adequate time to accept and prepare for palliative measures -Specifics of palliative measure will be discussed with the healthcare provider and family in detail and put into action-Family will be provided with appropriate time and conditions to cope with death; patient will pass with maximal comfort and dignity6324600762000 Student Clinical Self-AppraisalWeekly (turn in with Care Plan/Map)Student : Sara Hannah Course: Nurs 4810 Instructor: Mia Alcala-Van HoutenInstructions: Please evaluate your performance during clinical today using the following concepts:Patient AdvocateProfessional DemeanorFlexibleCritical ThinkingCommunication/rapportPeer SupportSelf-InitiatedTeam Player Skill AcquisitionSafetyOrganizedEducatorLeadershipWell-preparedDependableNursing ProcessKnowledgeableAreas of Strength Today (Date) Communication with multiple family membersProfessional demeanor while talking about a difficult subject with the family of the patientAreas Needing Growth-Include plan of improvement Being knowledgeable about the palliative process and what it entailsNursing process- need to do some evidence-based research on palliative care Instructor Comments:NURS 4810Plan of Care EvaluationStudent Name: Sara Hannah Date: Week#: Faculty: 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.) _________/10a.????? Physical datab.????? Health historyc.?????? Interventions as ordered 2. Each medication includes (10 pts.) _________/10a.????? Name (Trade & Generic)b.????? Rationalec.?????? Side effectsd.????? Nursing Implications 3. Laboratory Data (10 pts.) _________/10a.????? Patient Values and Trendsb.????? Etiology & Implications for the patient4. Concept Map includes all appropriate physiologic, psychologic or social problems, discharge planning & pt. education (20pts):? _________/205.??? 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:??????????? ................
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