example of excellent write-up

8/3/2019 Example of Excellent Write-up

1/18

5/3/2012

Page 1

N355 MEDICAL-SURGICAL ROTATION

Clinical Write up

Student name: ___________________________ Date: ____________

DIRECTIONS:1. Prior to first day of clinical: Complete sections 1 -3, 6-9 and show these sections to instructor at the beginning of the

first clinical day2. During the first clinical day: Complete sections 4-5 and your clients physical assessment3. Beginning of second clinical day: show sections 10 through 12 to instructor at the beginning of the second clinical day4. During second clinical day, revise document as needed5. Two Complete write-ups to be handed in during each of the clinical rotations this quarter

**********************************************************************************************************************

1. DEMOGRAPHICS and VITAL SIGNS VS DAY 1 DAY 20715 0720

Client Initials: xx Temp 99.7 Ax 100.2 -Oral

Age and gender: xx & xxxxxx P 106 105

Date of hospital admit: xx/xx/xx R 23 26

Dates cared: for xx/xx/xx & xx/xx/xx BP 117/39 128/41

Allergies: Codeine, Sulfites, red dye. Unable to locateallergy response in medical chart.

Pain 0/10resting

0/10 -resting

Advanced directive: DPA is Nephew O2 sat 96% 97%

Code status: Full code

Wt: bed scale 76.1kg xx/xx/xx per chart

Height: *

BMI: *

Pain ssessment Scale: FLACC pain scale, Patient had 2/10 pain upon movement especially of fingers and extremities onxxxx and xxxxx.O2 sat: Ventilator Settings Day 1: PRVC, 40%O2, PEEP 10; Ventilator Settings Day 2: PRVC, 35% O2, PEEP 10

*Unable to locate patient height in medical chart and therefore unable to calculate BMI, patient does not require dailyweights due to low dose PO lasix and minimal edema (per xxx, RN).

2. BRIEF medical history (Reason for admission; medical diagnoses; surgeries; summarize hospital course);use bullet points

Quit smoking tobacco in xxxx

Hx of recurrent falls: xx/xx fractured R ilium, R inferior and superior ramus and sacrum

Admitted to xxxxxxxxxxx on xx/xx/xx for respiratory failure/ARDS/RLL pneumonia (S. pneumonia)/multilobarinfiltrates

Xx/xx/xx Admitted to xxxxxxxx for ventilator weaningo Medical Diagnoses: altered mental status, C. diff (xx/xx/xx treated with 2 weeks of Flagyl; last dose

xx/xx), rash (improved with Nystatin), metabolic alkalosis, UE basil ica vein thrombosis (L-arm, resolved

xx/xx/xx), UTI (resolved), chronic bronchitis and COPD, diabetes, osteoporosis, HTN, arthritiso Xx/xx Video-assisted fiberoptic bronchoscopy with bronchoalveolar lavageo xx/xx Echocardiogram: mildly sclerotic aortic and mitral valves but with normal function and no evidence

of wall motion with normal L ventricular systolic functiono xx/xx U/S guided thoracentesis of R posterior chest wallo xx/xx Percutaneous tracheostomyo xx/xx L radial arterial lineo xx/xx Head CT: negative for acute hemorrhage, showed microvascular changeso xx/xx liberated from ventilator to HFG @ 40% O2 and PEEP 5o xx/xx Emesis x3 with possible aspiration, FT off until 1800 when it was resumed at 15ml/hr, patient

reintubated3. PATHOPHYSIOLOGY: Describe all major conditions that might impact this hospitalization, including reason

for admission and any chronic illnesses impacted by this admission.


2/18

5/3/2012

Page 2Use a bullet list 3 - 5 bullets for pathophysiology, 2-3 bullets for treatment, 1 2 bullets for expected course,3-5 bullets for selectivenursing or laboratoryassessments related to condition

Acute Respiratory Distress Syndrome (ARDS): sudden and progressive form of respiratory failure which results indamage to the alveolar capillary membranes and causes them to become more permeable to intravascular fluid(Lewis et al., 2007). To understand ARDS, it helps to understand how the lungs work. When you breathe, airpasses through your nose and mouth into your windpipe. The air then travels to your lungs which contain smallsacs called alveoli. Small blood vessels called capillaries run through the walls of the air sacs. Oxygen passesfrom the alveoli into the capillaries and then into the circulatory system. Blood within the circulatory system

carries the oxygen to all parts of the body. In ARDS, infections, injuries, or other conditions cause the lung'scapillaries to leak more fluid than normal into the alveoli. This prevents the lungs from filling with air and movingadequate amounts of oxygen into the circulatory system. When this happens, the body's organs don't get theoxygen they need. Without oxygen, the organs may not work properly or may stop working altogether. Mostpeople who develop ARDS are hospitalized for a variety of problems associated with organ failure or insufficiency(THIS EXPLAINATION IS GREAT!)

o Treatment Administer oxygen to correct hypoxemia Mechanical ventilation provides additional respiratory support Some patients improve O

2perfusion when turned from the supine to the prone position (Lewis et

al., 2007)o Expected Course

Maintain adequate oxygenation and ventilation meanwhile preventing infection. xx vomited on

xx/xx with possible aspiration. Precautions have been taken to treat possible pneumonia r/t thisaspiration event.

Keep HOB at 30-45o

to decrease risk of further aspiration. Wean patient off ventilator as they become stronger and able to begin breathing on their own. xx

was weaned off the ventilator and placed on HFG on xx/xx but required reintubation on xx/xx.o Nursing/Laboratory Assessments

Assess respiratory rate, rhythm, breath sounds, pulse ox Assess ABG looking for respiratory/metabolic acidosis/alkalosis CXR to determine placement of endotracheal tube. Last PCXR was taken on xx/xx. Another

PCXR should have been done after reintubation to ensure proper endotracheal tube placement(unable to locate record).

COPD: airway obstruction that is worse with expiration, the presence of chronic bronchitis and emphysemacharacterize chronic obstructive pulmonary disease, underlying symptoms are dyspnea and wheezing, virtually

impossible to differentiate asthma from COPD (Lewis et al., 2007) (THIS DOES NOT DOMONSTRATE ANUNDERSTANDING THE DISEASE)o Treatment

Smoking Cessation will cause the accelerated decline in pulmonary function to slow andpulmonary function usually improves (Lewis et al., 2007). xx ceased tobacco use in xxxx afterhaving smoked for approximately 40 yrs (per spouse).

Bronchodilator drug therapy relaxes smooth muscles in the airway and improves the ventilation ofthe lungs.

Long-term O2 therapy improves survival, exercise capacity, cognitive performance and sleep inhypoxemic patients (Lewis et al., 2007). In COPD patients, there is a loss of elasticity anddecreased alveolar surface area on surrounding capillaries. This results in a decrease in airmovement in the alveolar space and therefore decreased perfusion of oxygen and carbon dioxidewhich leads to air trapping.

o Expected Course It is a preventable and treatable disease state, a disease state characterized by airflow

limitation that is not fully reversible (Lewis et al., 2007, p. 768). Maintain adequate oxygenation and ventilation Wean patient off ventilator as they become stronger and able to begin breathing on their own. xx

had weaned off the ventilator and was placed on HFG before having to be reintubated afterpossible aspiration.

o Nursing/Laboratory Assessments Assess respiratory rate, rhythm, depth, pulse ox, breath sounds Assess ABG looking for respiratory/metabolic acidosis/alkalosis Assess capillary refill to determine peripheral blood perfusion

S. pneumoniae: can be a community-acquired pneumonia (35%) or a hospital-acquired pneumonia; can infect theupper respiratory tract, the blood, and the nervous system; the organism is generally found in the nose and throat


3/18

5/3/2012

Page 3(Lewis et al., 2007). Risk factor for aspiration pneumonia is tube feedings (xx had high residual volumes prior toemesis and poss aspiration); infecting organism is usually one of the normal oropharyngeal flora such as S.pneumonia (Lewis et al., 2007). (THIS DOES NOT DOMONSTRATE AN UNDERSTANDING THE DISEASE)

o Treatment Antibiotic therapy. xxxx was immediately started on piperacillin/tazobactam (an extended

spectrum penicillin) to treat potential pneumonia r/t possible aspiration. When giving antibiotics it is important to keep in mind the development of multidrugresistant

organisms and a patients sensitivity to certain antibiotics. Supportive measures: oxygen therapy to treat hypoxemia, analgesics to relieve chest pain, and

antipyretics for significantly elevated temperature. Important to provide nutritional intake to meet the demands of the patient since they often loose

weight because of increased metabolic demands. IV administration of fluid and electrolytes isnecessary in xxs case since she is strictly NPO. Monitor renal function and cardiac function andadjust fluid intake appropriately so as not to cause fluid-overload.

o Expected Course Physical assessment: may find dullness to percussion, increased fremitus (vibratory tremors felt

through chest wall upon palpation), bronchial breath sounds, and crackles. May manifest with headache, fatigue, sore throat, nausea, vomiting and diarrhea. In uncomplicated cases, the patient will respond to drug therapy within 48-72 hours.

o Nursing/Laboratory Assessments Change in fever

Sputum purulence/Resp Secretions presence of pus Leukocytosis monitor serum blood values to determine if there is an increase in leukocytes,

WBC Oxygenation Chest x-ray patterns: concentrating on location and size of infiltrates

Be sure to include your patients assessment findings and appropriate teaching related to their pathophysiologyDay 1

- General UE +1 edema patient unable to be taught, but arms were elevated on pillows- HR ranged from 106 122monitor patient for sinus tachycardia with possible PACs- Thick, yellow secretions unable to teach patient how to use call light and how/when to notify staff of

suctioning need, provide routine respiratory assessments and PRN suctioning- No spontaneous movement - unresponsive

- Patient appeared to have 2/10 pain (FLACC Pain Assessment Tool) when her fingers were straightened,most likely due to previous diagnosis of arthritis. While performing PROM, OT explained to xx the need tostretch and move her fingers.

- Left FA wound (present upon admission to RH and the result of an infiltrated peripheral IV line) dressingchanged on xx/xx and it was requested that dressing be removed three days later. However, this dressingwas still intact on xx/xx. Xxxxx, the wound RN, was consulted and she recommended this dressing beremoved. I removed dressing and irrigated wound with NS on xx/xx and placed a new duoderm dressingsecured with tegaderm per Xxxxx wound instructions located in the chart. The dressing was dated, timed andinitialed.

- ~11:15, pressure increased to 60s on the ventilator, mucous obstruction suspected and patient wassuctioned and received several high pressure ambu bag breaths. Pressures decreased to 33 which indicatedthe mucous plug obstruction had been removed. (Mucous plug acts as a valve allowing air into the lungs withevery breath, but not allowing air to escape the lungs during exhalation which causes the increased pressuresin the lungs).

Day 2- 2+ pitting edema on RUE, arms elevated on pillows. Xx startled to her name and opened her eyes when she

was rotated in bed. She had no spontaneous movements. Before every procedure/medication administrationetcI informed xx of what was going to happen and talked to her through the procedures especially theuncomfortable OT exercises with her hands and fingers.

- @ 0920, her 0900 meds were administered which included FeSo4. Approximately 0940, xx began to vomitwhich significantly increased her risk for aspiration. She was immediately suctioned and her FT was stopped.She was given a bed bath and her linens were changed. She was again placed with the head of her bed at a30 degree angleone intervention to prevent/limit aspiration. Its possible the emesis was a reaction to the tothe FeSO4 and this was communicated to Dr. Xxxx during rounds. He proceeded to discontinue FeSO4. HerFT was resumed at 1030 at 30ml/hr and at 1310 it was increased to 50ml/hr (the desired rate). xx was not


4/18

5/3/2012

Page 4responsive but she was reassured throughout the cleaning process and provided necessary care. Her PEGtube dressing, PICC line dressing and trach dressing were also changed to decrease risk of infection.

- @ 0730, she had clear lung sounds in the LUL and RUL and crackles in RML and diminished with crackles inthe RLL and LLL. @ 1230, she had clear and diminished lung sounds in the LLL but crackles in the RLL(diminished), RML, RUL, and LUL. This assessment is critical following her emesis and aspiration event fromthe morning. xx was unable to be taught due to her unresponsiveness.

- I was able to discuss appropriate hand-washing techniques with family members and visitors.

List two physiological nursing diagnoses related to this patients pathophysiology1. Impaired gas exchange r/t alveolar-capillary membrane changes2. Risk for infection r/t possible aspiration and exposure of pathogens to lungs

4. DEVELOPMENTAL ASSESSMENT: (refer to growth charts with infants & children);Compare and contrast your client to typical growth & development issues for someone of this age and sex? Seebulleted chart below.What are expected healthcare concerns for someone of this age and sex? Are these your clients concern s?

Expected Healthcare Concerns: decreased peripheral circulation (yes, this is pertinent to xx since she hashypertension and diabetes, both of which can decrease peripheral circulation), declining cardiac and renalfunction, decreased response to stress and sensory stimulation, skeletal decline (yes, this is pertinent to xx due toher osteoporosis and arthritis), decrease tolerance to heat and cold (this is not a major concern of xx), loss ofteeth leading to changes in food intake (this is not a major concern at this time), atrophy of reproductive organs

(this is not a major concern); xxs major healthcare concerns at this point in time are weaning off the ventilatorwhile maintaining appropriate oxygenation, maintaining a healthy weight by receiving adequate nutrients andmaintaining ROM in all extremities to ensure a more timely rehabilitation.

Describe one example of health care promotion for this client based on their growth and development and healthconcerns.

When teach opportunities arrive teach xx to practice good health habits, such as proper diet and hygiene,adequate rest, and regular exercise all of which can maintain the natural resistance to infecting organisms (i.e.pneumonia) and aid in the management of diabetes and hypertension.

Incentive spirometry use, deep breathing and effective coughing along with adequate fluid intake will promotelung expansion and secretion mobilization which will improve O2 perfusion and decrease risk of further infection.

Bullet important points of expected

development

Your patients actual stage with supporting assessment

findings

Decreased peripheral circulation

Declining cardiac and renalfunction

Decreased response to stressand sensory stimulation

Skeletal decline

This is a concern for xx due to her diabetes andhypertension which can decrease blood flow to theextremities. Peripheral pulses 2+/1+, cap refill < 3 sec infingers and toes.

This is a concern for xx since her body has experiencedincreased levels of stress related to sepsis, pneumonia andher recent aspiration. S1S2 sounds present with sinustachycardia (106122), and occasional PACs, urinaryoutput (400ml between 0700-1500) patient takes 20mg lasixorally, creatinine 0.44 on xx/xx indicative of inadequateprotein intake and does not indicate renal failure.

Patient was unresponsive to verbal stimuli and showed signsof pain when fingers were manipulated (2/10 on FLACC PainAssessment Scale), she opened her eyes when her positionwas changed to perform a full skin assessment and listen toposterior lung sounds.

OT and PT conducted PROM on all extremities but sheresisted manipulation of her fingers. She was unable to sit inchair due to her increased work in breathing as evidenced byher RR which was 24-26/12. This is not a major concern ofxx/xx at the moment. Instead her body is recuperating from apreviously diagnosed and treated sepsis, pneumonia andaspiration events. Once those conditions are managed, thensensory stimulation and ROM will be important during her


5/18

5/3/2012

Page 5rehabilitation.

xx has osteoporosis and arthritis both of which affect herskeletal system. She resisted PROM exercises in her fingersmost likely due to arthritis. She takes tums as a calciumreplacement/supplement and did not show signs ofhypocalcemia and/or hypercalcemia.

5. FAMILY ASSESSMENT: (family composition, # and ages of siblings (for child), occupation/work, retirement,

education, family residence and other relevant information that may influence planning and care) Lived independently at home with husband in Xxxxx They identify with the Catholic faith Husband diagnosed with early stage Alzheimers disease Patient was caregiver for husband at their residence before hospitalization Have 4 nieces and 2 nephews Nephew who is DPA is currently caring for patients husband at his residence durin g her hospitalization Patient used to be seamstress/sewing but is now retired

Two psychosocial nursing diagnoses related to development/family/psychosocial issues are1. Interrupted family process r/t family roles shift, shift in health status of family member, situational crises2. Risk for spiritual distress r/t life change, social alienation and chronic illness

6. DESCRIBE TYPE AND WHY THESE INTERVENTIONS ARE ORDERED FOR YOUR PATIENT:

Type and rationaleand relevant nursing assessments

What outcomes areassociated with thesetreatments?

Diet: (for children includefluid requirements,calculations of fluid andcaloric needs)

Feeding tube formula/strictly NPO atrisk for aspiration, patient sedated;Rationale: provide adequate nutrition w/orisk of aspiration; assess for residualvolume following NG feeding. xxxxreceives Nutren pulmonary TF with a goalrate of administration at 45 ml/hr. Onxx/xx, after patient had emesis x 3, TF

was stopped @ 1230 and restarted at1800 at 15ml/hr. Rationale: This lowerrate is to reduce likelihood of aspiration,reduce volume of residual output and stillstimulate the GI tract and providenutrients to the patient.

Patient maintaining weight @xxxx kg. Patient weighed xx kgupon admission on xxxxxxx.Precautions taken to preventaspiration, provide nutrientsneeded for skin healing,Nutritionist calculated xxxxxxcaloric need and increased her

tube feeding rate to 50ml/hr onxx/xx.

xx had emesis and aspirated at~0940 on xx/xx. Her FT wasstopped and resumed @ 1030at 30ml/hr. It was increased to50ml/hr @ 1310.

Activity: Patient on rotating bed which turns herfrom side-to-side q15 minutesRationale: prevent pressure ulcers,facilitate adequate lung expansion,discourage pooling of secretions; assessskin q shift

OT PROM bilateral upper extremitiesevery week day; assess for contractorsand muscle atrophyRationale: redistributes synovial fluidaround the joints which decrease risk ofcontractures and increases relaxation,

Patient unable to sit in chair orchange position in bed.However, her O2 sat stayedconsistent between 96-97%while in bed. She did experiencea mucous plug on xx/xx but thiswas dislodged promptly by RT,no new skin breakdown

xx did not assist PT/OT inPROM exercises. Contracturesare in the early stages on herfeet and she did not respondfavorably to PROM exerciseswith her fingers. Her hands andfingers were placed in splints tofacilitate movement and preventcontractors.


6/18

5/3/2012

Page 6Treatments (such asdressing changes,OT/PT):

L arm/wrist wound, dressing changed onxx/xx per wound care instructions locatedin chartduoderm applied and securedwith tegaderm. The dressing was dated,timed and initialed.Rationale: By dressing the wound, it isprotected and provides the necessaryenvironment for the wound to heal.

Necessary to assess wound for signs ofinfection as well as evaluate the healingprocess.

Skin cream/powder applied to yeastyareas (under breasts and armpits andunder pannus) including groin treatyeast infections; assess for signs ofinfection including redness, edema,ecchymosis, drainage and approximation

(REEDA)

Sequential Compression Devices (SCD)applied daily to patients lower legsRationale: to increase venous return anddecrease risk of developing DVT in thelower extremities; assess for signs of DVT(redness, increased skin temperature,pain)

I did not observe wound onxx/xx when dressing was firstapplied so I did not have a frameof reference to compare it to. xx,however, was able to assess thewound on xx/xx and assisted myin changing the dressing onxx/xx. She indicated that the

wound had healed significantlyduring that time. There were nosigns of redness or drainage.The wound was healingappropriately.

Powder applied to redden skinunder skin folds, armpits,breasts and on coccyx. RNdescribed yeasty infection inperi-area to be much improvedsince xx/xx. Dark reddened skinwas observed on coccyx with no

new skin breakdown.

xx had 1+ and 2+ pedal pulseson xx/xx and xx/xx respectively.Her legs were of normal roomtemperature and there were noreddened or hot areas found.She did not show signs of painwhen her legs were manipulatedwith movement.

Additionalinterventions:(chemsticks, pulse

oximetry, etc.)

Chemstick q6h;Ratioanle: patient is diabetic andimportant to detect hypoglycemic or

hyperglycemic episodes; assess patientfor signs of hyperglycemia orhypoglycemia

Continued pulse ox; patient on ventilatorand the RN needs to know how patient isoxygenating at all times.Rationale: indicates the appropriatenessof ventilation settings, assess lung soundsregularly and assess for possiblesuctioning need. Early prevention ofcomplications.

Blood sugar was 191 on xx/xxand 4 units of regular insulinwas administered. Blood sugar

was 146 on xx/xx and 2 units ofregular insulin wasadministered. She showed nosigns of hyperglycemia on eitherday.

xx maintained oxygenationbetween 96-97% on xx/xx andxx/xx. She was on PRVCventilation with 40% O2 on xx/xxand 35% O2 on xx/xx with aPEEP of 10 on both days. Shedid experience a mucous plugon xx/xx and this was noticedwhen her ventilator alarm whenoff when her peak pressuresincreased to the 60s. This plugwas immediately dislodged bythe RT after thorough suctioningand firm ambu-bag breaths.


7/18

5/3/2012

Page 77. MEDICATIONS:Please complete table for all regularly scheduled medications, given over the entire 24 hour

day and for any prn meds given within the past 24 hours for this patient

Drug/Drug Class

Be sure toincludeHOW/WHY the

drug works

Dose, route,frequency

Why orderedfor thisclient

Nursing assessmentsand interventions r/tmedication

Evaluation of Rx effect,including possible sideeffects, adverse reactions,etc.

xxxxxxxxxxxAntiulcer Agent/Proton PumpInhibitor

Binds to enzymeof gastric parietalcells in presenceof acidic gastricpH, prevents finaltransport ofhydrogen ions into

gastric lumen

40 mg oral susp.

0630

Prophylaxisfordevelopinggastric ulcers

Monitor for epigastric orabdominal pain, andfrank or occult blood instool, emesis or gastricaspirate

Day 1: No abdominal painupon palpation, no bloodobserved in stool, gastricresidual or emesis.

Day2: No abdominal pain uponpalpation, no blood observedin stool, gastric residual oremesis.

xxxxxxxxxxDiuretic/ Loopdiuretic

Inhibitsreabsorption of Naand Cl from theloop of Henle anddistal renal tubule

20 mg tablet POdaily

0900

Edema dueto renalinsufficiency,HTN

Monitor daily weight,intake and outputratios, amount andlocation of edema, lungsounds, skin turgor,mucous membranes,BP, HR

Day 1: Due to low dose POfurosemide and minimaledema, patient does notrequire daily weights (per RN).Total intake: 3048ml, totaloutput: 1700ml; no pittingedema, general 1+ edema UE;lung sounds clear in am,crackles in upper lobes inafternoon but clear aftersuctioning; BP 117/39, HR 106

Day 2: Intake between 0700and 1430 ~744ml, Outputbetween 0700 and 1430 ~400ml; 2+ pitting edema onright FA, no general edema;crackles in RML,RLL,LLL clearin LUL and RUL; BP 128/41;HR 105

xxxxxxxx(PotassiumBicarbonate)Mineral andelectrolytereplacement/supplement

Maintain acid-base balance,isotonicity, andelectrophysiologicbalance of the cell

20 meq packet FTdaily

0900

Treatment/prevention ofpotassiumdepletion

Monitor forsigns/symptoms ofhypokalemia(weakness, fatigue,arrhythmias, polyuria,polydipsia) andhyperkalemia (slow,irregular heartbeat,fatigue, muscleweakness, paresthesia,confusion, dyspnea,depressed STsegments, prolongedQT segments, widenedQRS complexes, lossof P waves, cardiacarrhythmias)

Day 1: No signs ofhypokalemia or hyperkalemia;no abdominal pain uponpalpation, no diarrhea, novomiting

Day 2: No signs ofhypokalemia or hyperkalemia;no abdominal pain uponpalpation, no diarrhea, patientvomited and aspirated (emesiscoming out through trach) @0940 most likely due to FeSO4administration @ 0920.


8/18

5/3/2012

Page 8

SE: abd pain, diarrhea,flatulence, nausea,vomiting

xxxxxAntianemic/Ironsupplement

Iron enters the

bloodstream andliver/spleen/bonemarrow where it isseparated out andbecomes part ofiron stores

300mg/5ml oralliquid FT daily

0900

Prevention/treatment ofiron-deficiencyanemia

Assess nutritionalstatus; assess bowelfunction for constipationor diarrhea; monitorHgb and Hct lab values

Day 1: +BS all quadrants, hadmedium sized bowelmovement on xxxxxxxx, tubefeeding increased to 50ml/hrdue to increased caloric needs

as determined by thenutritionist; Hgb and Hct labvalues increased betweenxxxx and xxxx but decreasedbetween xxxxx and xxxxx(aspiration event occurred onxxxxx).

Day 2: +BS all quadrants, lastBM on xxxxxxxx, ~20 minutesafter administering medication,patient aspirated. This wascommunicated to Dr. xxxxx

during rounds and hediscontinued this medicationb/c it likely irritated xxxxxxstomach and was theprecipitating factor to theemesis; tube feeding turned offimmediately following emesisand resumed @ 30ml/hr at1030, tube feeding increasedto 50ml/hr @ 1310

xxxxxxxxxxxxxWater solublevitamins

Vitaminsupplement

500 mg tab POdaily

0900

Treatmentandprevention of

vitamin Cdeficiencydue to NPOstatus

Monitor for vitamin Cdeficiency: scurvy(disease caused by

inadequate intake ofascorbic acid, whosesymptoms includefatigue, skin, joint andgum bleeding, impairedwound healing, dryskin, lower extremityedema), defectiveteeth, anorexia, anemia

Day 1: No signs or symptomsof scurvy, patient does havedecreased RBC, Hct, Hgb

likely due to inadequatenutritional intake

Day 2: No signs or symptomsof scurvy, patient does havedecreased RBC, Hct, Hgblikely due to inadequatenutritional intake

xxxxxxxxxxxLipid-loweringagent/ HMG-CoAreductase inhibitor

Inhibit enzymewhich isresponsible forcatalyzing an earlystep in thesynthesis ofcholesterol

20 mg tablet POHS

2100

Managementofhypercholesterolemia

Assess for abdominalcramps, constipation,diarrhea, flatus, rashes

Day 1: No abdominal painupon palpation, had mediumsized bowel movement on10/14/08

Day 2: No abdominal painupon palpation, had bowelmovement @ 0550 on10/16/08

xxxxxxxxLaxative/stool

250mg/25ml oralliquid FT daily

Prevention ofconstipation

Assess for abdominaldistension, presence of

Day 1: Abd slightly firm onpalpation, + BS all quadrants,


9/18

5/3/2012

Page 9

softener

Promotesincorporation ofwater into stoolresulting in softerfecal mass

0900bowel sounds, andusual pattern of bowelelimination

Assess color,consistency andamount of stoolproduced

had medium sized bowelmovement on xxxx (notpresent to assess consistencyand amount of stool produced)

Day 2:Abd slightly firm onpalpation, + BS all quadrants,had bowel movement at 0550

(not present to assessconsistency and amount ofstool produced)

xxxxxxxStimulant laxative

Accumulation ofwater in largeintestine andincreasedperistalsis

1 tablet PO HS

2100

Treatment ofconstipationfromimmobility

Assess for abdominaldistension, presence ofbowel sounds, usualpattern of bowelfunction

Assess color,consistency, andamount of stoolproduced

Day 1: Abd slightly firm onpalpation, + BS all quadrants,had medium sized bowelmovement on xxxxx (notpresent to assess consistencyand amount of stool produced)

Day 2: Abd slightly firm onpalpation, + BS all quadrants,had bowel movement at 0550

(not present to assessconsistency and amount ofstool produced)

xxxxxxxxxxxxxxxxxxxxxxxxMineral andelectrolyereplacement/supplement

Calcium isessential fornervous,

muscular, andskeletal systems,bone formationand bloodcoagulation;activator intransmission ofnerve impulsesand contraction ofcardiac, skeletaland smoothmuscle

500 mg tablet POtid

0900, 1300, 1800

Adjunct inprevention ofpost-menopausalosteoporosis/treatmentandprevention ofhypocalcemia

Monitor for symptomsof hypocalcemia(paresthesia, muscletwitching,laryngospasm, colic,cardiac arrhythmias,Chvosteks contraction of facialmuscles in response toa light tap over the

facial nerve in front ofthe ear or Trousseaussign carpal spasmsinduced by inflating aBP cuff on the arm)

Assess for heartburn,indigestion, and abdpain. Inspect abdomenand auscultate bowelsounds.

Day 1: No signs ofhypocalcemia, no signs ofabdominal pain uponpalpation, + BS all quadrants.

Day 2: No signs ofhypocalcemia, no signs ofabdominal pain uponpalpation, + BS all quadrants.

xxxxxxxxxLaxative/Osmotics

Increases watercontent andsoftens the stool

20 gm FT daily

0900

Treatment ofconstipation

Assess for abdominaldistension, presence ofbowel sounds, andusual pattern of bowelelimination

Assess color,consistency andamount of stoolproduced

Day 1: Abd slightly firm onpalpation, + BS all quadrants,had medium sized bowelmovement on xxxxx (notpresent to assess consistencyand amount of stool produced)

Day 2: Abd slightly firm onpalpation, + BS all quadrants,had bowel movement at 0550(not present to assessconsistency and amount ofstool produced)

xxxxxxxxxxx 40mg/0.6ml oral Relief of Monitor for abdominal Day 1: No signs of abdominal


10/18

5/3/2012

Page 10

Antiflatulent

Causescoalescence ofgas bubbles

liquid PO qid

0900, 1300, 1800,2100

Dose: 80mg

painfulsymptoms ofexcess gas inthe GI tract

pain, distension, BS pain upon palpation, abdslightly firm, + BS all quadrants

Day 2: No signs of abdominalpain upon palpation, abdslightly firm, + BS all quadrants

xxxxxxxxxxxxxxAnticoagulant/

Antithrombotic

Potentiatesinhibitory effect ofantithrombin,preventsconversion ofprothrombin tothrombin and offibrinogen to fibrin

5000 units/1ml SQq8h

0600, 1400, 2200

Prophylaxisand

treatment ofDVT(resolvedxxxxxxx)

Assess for signs ofbleeding

Day 1: No signs of bleeding instool, gastric residual

etcsmall bruises noted onabdomen at sites of SQheparin administration which isa normal finding

Day 2: No signs of bleeding instool, gastric residual oremesis, small bruises noted onabdomen at sites of SQheparin administration which isa normal finding

xxxxxxxxxxxxxxAntiemetic

Stimulates motilityof upper GI tractand acceleratesgastric emptying,prevents andrelieves nauseaand vomiting

10 mg tablet POq6h

0000, 0600, 1200,1800

Preventaspiration

Assess for abdominaldistension and bowel

sounds

Day 1: Abd slightly firm, + BSall quadrants

Day 2: Abd slightly firm, + BSall quadrants, patient vomitedand aspirated @ 0940

xxxxxxxxxxxxxxxxAntidiabetic/pancreatic

Lowers blood

glucose bystimulatingglucose uptake inskeletal muscleand fat, inhibitinghepatic glucoseproduction

**High Alert Med**

100 units/ml SQ

1800

Dose: 10 units

Managementof diabetes

Assess for signs andsymptoms ofhypoglycemia (anxiety,restlessness, moodchanges, tingling in

hands, feet, lips, ortongue, chills, coldsweats, confusion, coolpale skin, difficulty inconcentration,drowsiness, headache,irritability, nausea,nervousness, rapidpulse, shakiness) andhyperglycemia(confusion, drowsiness,flushed, dry skin, fruit-like breath odor, rapid,deep breathing,frequent urination, lossof apptit, tiredness orweakness), monitorblood glucose regularly

Day 1: BS 191 4 units ofregular insuli SQ PRN per thesliding scale

Day 2: BS 146, 2 units of

regular insulin SQ PRN per thesliding scale; discontinued byDr. xxxxx on xxxxxxx. Unsurewhy this was discontinuedsince patient routinely hadhigh chemstick results.Perhaps this is because thePRN regular insulin iscontrolling blood sugar well.

xxxxxxxxxxxxxxxxAntifungal

Affect synthesis ofthe fungal cellwall, allowingleakage of cellularcontents

56.7 gm bottle BIDand PRN

0900, 1800

Treatment offungalinfection

Inspect involved areasof the skin

Day 1: Reddened skinunderneath skin folds, armpits,breasts and on coccyx

Day 2: Reddened skinunderneath skin folds, armpits,breasts and on coccyx


11/18

5/3/2012

Page 11

xxxxxxxxxxxxxxxxxxxxxxxAnti-infective/Extendedspectrum penicillin

Binds to bacterialcell wall

membrane,causing cell death

4.5 gm inj in 100ml NS bag q6h

0400, 1000, 1600,2200

*Started xxxxxfollowing

aspiration

Treatpotentialpneumonia r/taspiration onxxxxxxxx andxxxxxxxx

Assess patient forinfection (VS, wound,sputum, urine, stool,WBC), ascultate lungsounds

Day 1: Temp 99.7F axillary inam, Temp 100.6F axillary inpm, no growth in blood cultureafter 24 hours; lowerrespiratory sputum culture +for gram rods; lung soundsclear in am, crackles in upperlobes in afternoon but clear

after suctioning

Day 2: Temp 100.2F oral inam, Temp 101.0F oral in pm,no growth in blood culture after48 hours; RN reports floragrowing in lower respiratorysputum culture does notrequire vanco to treat (per Dr.Clark during rounds) andtherefore vanco discontinued;crackles in RML,RLL,LLL clearin LUL and RUL

XxxxxxxxxxAnti-infective

Binds to bacterialcell walls resultingin cell death

1000 mg vial in250ml NS bagq12h

Started xxxxxxxxfor possibleaspirationpneumonia

0200, 1400

Treatpotentialpneumonia r/taspiration onxxxxxxxx andxxxxxxxx

Assess patient forinfection (VS, wound,sputum, stool, WBC),ascultate lung sounds

Day 1: Temp 99.7F axillary inam, Temp 100.6F axillary inpm, no growth in blood cultureafter 24 hours; lowerrespiratory sputum culture +for gram rods; lung soundsclear in am, crackles in upperlobes in afternoon but clearafter suctioning

Day 2: Temp 100.2F oral inam, Temp 101.0F oral in pm,no growth in blood culture after

48 hours; crackles inRML,RLL,LLL clear in LUL andRUL; Vanco discontinued afterreceiving vancomycin troughlab value which was higher(14.1) than the range (5-10)and lab culture results whichshowed no organisms thatrequire treatment with vanco(per Dr. xxxxx during rounds).

xxxxxxxxxxxxxxxxxxxxxAntidiabetics/Pancreatics

Lower bloodglucose bystimulatingglucose uptake inskeletal muscleand fat andinhibiting hepaticglucoseproduction

100units/1ml400 = 14 units,call MD!

Managementof DiabetesMillitus

Assess for signs andsymptoms ofhypoglycemia (anxiety,restlessness, moodchanges, tingling inhands, feet, lips, ortongue, chills, coldsweats, confusion, coolpale skin, difficulty inconcentration,drowsiness, headache,irritability, nausea,nervousness, rapidpulse, shakiness) and

Day 1: BS 191 4 units ofregular insuli SQ PRN per thesliding scale; no signs ofhyperglycemia

Day 2: BS 146, 2 units ofregular insulin SQ PRN per thesliding scale; no signs ofhyperglycemia


12/18

5/3/2012

Page 12

**High Alert**hyperglycemia(confusion, drowsiness,flushed, dry skin, fruit-like breath odor, rapid,deep breathing,frequent urination, lossof apptit, tiredness orweakness), monitor

blood glucose regularly

8. LAB TESTS (blood, urine, sputum, cultures, etc): Please complete table for laboratory tests pertinent to thereason for admission and clients health history.

TEST/DATE For lab tests:RANGE/FINDINGS

What is thepurpose of thistest?

Why ordered forthis patient (whatis the clinicalsignificance forthis patient?)

Nursing actions that requireassessment or follow up (npo,diet changes, med change)

VancomycinTrough

Xx/xx/xx

5 10 / 14.1 Indicates theamount of

vancomycin inthe patientsblood streamimmediately priorto administeringthe next vancodose.

Patient is onvancomycin. Want

to determine if shehas a therapeuticdose onboardimmediately prior toreceiving her nextdose.

Trough value is high. Thisindicates that the vancomycin

dose needs to be decreased.However, lab blood culturesfound flora that does not requiretreatment with vancomycin andvanco was discontinued onxxxxxxxx.

WBCXx/xx/xx

4.00 11.0 / 19.2 The WBC countindicates thedegree ofresponse to apathologicalprocess

Increased levelsindicate leukocytosisor infection orinflammation

Leukocytosis foundin majority ofpatients withbacterial pneumonia(Lewis et al., 2007)

Day 1: Temp 99.7F axillary inam, Temp 100.6F axillary in pm,no growth in blood culture after24 hours; lower respiratorysputum culture + for gram rods;lung sounds clear in am, cracklesin upper lobes in afternoon butclear after suctioning, increasedtemperature indicates the body isfighting an infection most likely inthe lungs following aspiration

Day 2: Temp 100.2F oral in am,Temp 101.0F oral in pm, nogrowth in blood culture after 48hours; RN reports flora growing inlower respiratory sputum culturedoes not require vanco to treat(per Dr. Clark during rounds) andtherefore vanco discontinued;

crackles in RML,RLL (commonfollowing aspiration) and LLL,clear in LUL and RUL, increasedtemperature indicates the body isfighting infection most likely in thelungs following aspiration

RBCXx/xx/xx

4.00 5.20 / 3.28 RBCs containHgb, which isresponsible fortransport andexchange ofoxygen, so # of

Monitor for anemia(palpitations,dyspnea,diaphoresis, pallor,

jaundice, pruritus,increased HR

Lab values indicate E.W. hasanemia due to inadequatenutritional intake. She hadincreased HR at 106 and 105 onxxxxx and xxxxx respectively.


13/18

5/3/2012

Page 13

circulating RBCsis important.Decrease inRBC, Hgb andHct indicatesanemia.

HgbXx/xx/xx

12.0 16.0 / 9.9 Measures Hgbwhich carries

oxygen to andremoves carbondioxide fromRBCs

Monitor effects ofacute bleeding from

the mouth, evaluatesuspected anemia,monitor fluidimbalances

Lab values indicate E.W. hasanemia due to inadequate

nutritional intake. She hadincreased HR at 106 and 105 onxxxxx and xxxxx respectively;xxxx did not have acute bleeding

HctXx/xx/xx

36.0 46.0 / 29.5 Measure % ofRBCs in avolume of wholeblood. Decreaseof RBC, Hgb andHct indicateanemia.

Monitor effects ofacute bleeding fromthe mouth, evaluatesuspected anemia

Lab values indicate xxxx hasanemia due to inadequatenutritional intake. She hadincreased HR at 106 and 105 onxxxxxx and xxxxx respectively; xxdid not have acute bleeding

CreatinineXx/xx/xx

0.50 1.20 / 0.44 To evaluate renalfunction

To determine ifpatient has kidney

failure (increasedvalues) orinadequate proteinintake/decreasedmuscle mass(decreased values)

Low value most likely indicatesinadequate protein intake. The

nutritionist evaluated E.W. on10/15/08 and determined that hercaloric needs were higher thanthe rate at which she wasreceiving her tube feedingformula and therefore her formularate was increased to 50ml/hr.

WBC10/13/08

4.00 11.0 / 11.9 The WBC countindicates thedegree ofresponse to apathologicalprocess

Increased levelsindicate leukocytosisor infection orinflammation

Leukocytosis found

in majority ofpatients withbacterial pneumonia(Lewis et al., 2007)

Monitor for signs of infection suchas increased temperature (whichis seen on 10/15 and 10/16),continue to ascultate the lungslistening for crackles and othersigns of pneumonia (i.e. infiltrates

on pCXR). Monitor wound on ptsleft FA for signs of infection.

RBC10/13/08

4.00 5.20 / 3.54 RBCs containHgb, which isresponsible fortransport andexchange ofoxygen, so # ofcirculating RBCsis important.Decrease in

RBC, Hgb andHct indicatesanemia.


jaundice, pruritus,increased HR

Lab values indicate E.W. hasanemia, most likely stemmingfrom the fact that she is lackingexcellent nutrition and thereforehas a decrease in RBCproduction.

Hgb10/13/08

12.0 16.0 / 10.8 Measures Hgbwhich carriesoxygen to andremoves carbondioxide fromRBCs

Monitor effects ofacute bleeding fromthe mouth, evaluatesuspected anemia,monitor fluidimbalances

Lab values indicate E.W. hasanemia due to inadequatenutritional intake. She hadincreased HR at 106 and 105 on10/15 and 10/16 respectively;E.W. did not have acute bleeding

Hct10/13/08

36.0 46.0 / 32.1 Measure % ofRBCs in avolume of wholeblood. Decrease

Monitor effects ofacute bleeding fromthe mouth, evaluatesuspected anemia

Lab values indicate E.W. hasanemia due to inadequatenutritional intake. She hadincreased HR at 106 and 105 on


14/18

5/3/2012

Page 14**AllinformationobtanedfromXxxx

xx etal.(xxxx)**Noother labresutswerelocated inpatie

ntschar.

Creatinine didnotchangesignificantly

betweenxx/xxandxx/xx.Decreasedcreaininevalues

indicativeofdecreased

muscle mass owing to debilitating disease/increasing age or inadequate protein intake.

Trends:

Date RBC Hgb Hct WBC

Xx/xx 3.31 10.2 29.6 -

of RBC, Hgb andHct indicateanemia.

10/15 and 10/16 respectively;E.W. did not have acute bleeding

Glucose10/6/08

60 90 / 129 Measure amountof glucosepresent in serum;important sincepatient is diabetic

Patient is diabetic,must monitor orhypoglycemia andhyperglycemia, mayadminister insulin

according to theglucose value andthe sliding scale

BS > 120, 2 units of insulinregular administered, monitor forsigns of hyperglycemia; continuechemstick q4h

Creatinine10/6/08

0.50 1.20 / 0.43 To evaluate renalfunction

To determine ifpatient has kidneyfailure (increasedvalues) orinadequate proteinintake/decreasedmuscle mass(decreased values)

Low value most likely indicatesinadequate protein intake. Thenutritionist evaluated E.W. on10/15/08 and determined that hercaloric needs were higher thanthe rate at which she wasreceiving her tube feedingformula and therefore her formularate was increased to 50ml/hr.

Albumin

10/6/08

3.1 5.2 / 2.3 Measure main

transport proteinin the body

Decreased levels

indicative ofnutritional deficiency

Continue nutren pulmonary tube

feeding 50ml/hr perrecommendation of nutritionist;strictly NPO; test normalconsidering patient does not takein any nutrients/food PO andindicates adequate but notexcellent nutritional status

RBC10/6/08

4.00 5.20 / 3.31 RBCs containHgb, which isresponsible fortransport andexchange ofoxygen, so # of

circulating RBCsis important.Decrease inRBC, Hgb andHct indicatesanemia.


jaundice, pruritus,increased HR)

Lab values indicate E.W. hasanemia due to inadequatenutritional intake. She hadincreased HR at 106 and 105 on10/15 and 10/16 respectively.

Hgb10/6/08

12.0 16.0 / 10.2 Measures Hgbwhich carriesoxygen to andremoves carbondioxide fromRBCs

Monitor effects ofacute bleeding fromthe mouth, evaluatesuspected anemia,monitor fluidimbalances

Lab values indicate E.W. hasanemia due to inadequatenutritional intake. She hadincreased HR at 106 and 105 on10/15 and 10/16 respectively;E.W. did not have acute bleeding

Hct

10/6/08

36.0 46.0 / 29.6 Measure % of

RBCs in avolume of wholeblood. Decreaseof RBC, Hgb andHct indicateanemia.

Monitor effects of

acute bleeding fromthe mouth, evaluatesuspected anemia

Lab values indicate E.W. has

anemia due to inadequatenutritional intake. She hadincreased HR at 106 and 105 on10/15 and 10/16 respectively;E.W. did not have acute bleeding


15/18

5/3/2012

Page 15

Xx/xx 3.54 10.8 32.1 11.9

Xx/xx 3.28 9.9 29.5 19.2

RBC/Hgb/Hct values increased between xx/xx and xx/xx but still remained low. This indicates that anemia is resolving,mostly likely due to increased oral iron intake. Xx aspirated on xx/xx, her tube feeding was immediately decreased andresumed at 30ml/hr later in the day. Her body was under stress which indicates why the RBC/Hgb/Hct values decreasedon xx/xx. Her WBC increased dramatically between xx/xx and xx/xx which indicates infection most likely in the lungs

following the aspiration event on xx/xx. On xx/xx her tube feeding rate was increased to 50ml/hr due to her increasedcaloric needs as determined by the nutritionist and to provide additional energy her body will need to fight off infection.

9. DIAGNOSTIC TESTS and Procedures (x-ray. ECG, EEG, ultrasound, radiography, etc.). Please complete table fordiagnostic tests pertinent to the reason for admission and clients health history.

Allotherdiagnostictests

werecompletedwhilepatientwasadmittedatXxxxxxx

xxxxxxx.

10. INTEGRATION OF CARE: What are the relationships between the pathophysiology, priority nursing

diagnoses, outcomes, medications, labs, and treatments for this patient at this time?

xx was weaned off the ventilator and decannulated on xx/xx and subsequently responded well for 72 hours. Onxx/xx she aspirated and had to be reintubated. Since that time she requires full ventilator support at a PEEP of 10Dr. Xxxx immediately prescribed Piperacil lin/Tazobactam to be started on xx/xx to treat potential pneumonia thatcould develop from the aspiration event. Vancomycin was added on xx/xx after receiving positive sputum culture.This was discontinued on xx/xx after learning that the organisms present in the sputum culture would not respondto vancomycin because they were gram and vancomycin targets gram + organisms. After the aspiration event

on xx/xx, xx/xx WBC count increased from 11.9 to 19.2 indicative of infection. Therefore, respiratory assessmentis crucial in assessing the patients ability to fight the infection and the location of infection. It will be imperative tocontinue PCXR to assess for infiltrates. xx will require continued O2 monitoring as she fights infection andcontinues on the ventilator. In addition, her temperature must be taken regularly to assess for fever, another signof infection. As xxs body fights infection and pneumonia, it is imperative that she is receiving proper caloric intakevia her feeding tube and this was increased by the nutritionist on xx/xx. Following her aspiration event on xx/xx,FeSO4 was discontinued and aspiration precautions still need to be implemented (strictly NPO, head of bed at 30etc). The latest two aspiration events have proved to be a setback in xxs recovery but with early detection ofproblems, proper interventions can be implemented to eliminate further complications.

11. NURSING PROCESS AND PLAN OF CARE

TEST/DATE What is the purposeof this test (textreference)

Why ordered for thispatient (related toprimary dx?) Plan ofcare implications?

Nursing actions that require assess orfollow up (npo, diet changes, medchange)

PCXRXx/xx/xx

Examine pulmonary,cardiac and skeletalsystems

Determine location ofPICC line, PEG tube,and endotracheal tube;Evaluate cardiovascularhealth and pulmonarystatus (i.e. infiltrates r/tpneumonia)

Assess respiratory function: Day 1PRVC, 40% O2, PEEP 10, RR 24/12,lungs clear after suctioning, thick yellowsecretions; Day 2 PRVC, 35% O

2,

PEEP 10, RR 26/12, crackles in LUL,RUL, RML, RLL, clear sounds in LLL(crackles due to aspiration event morningof xx/xx)

WBC elevated on 10/14, look forinfiltrates on following PCXR which, ifpresent, will be indicative of infection(pneumonia)

ECGXx/xx/xx

Assess cardiacfunction

Compare findings toECG from xx/xx anddetermine if there is any

cardiac decline

Assess cardiac function: Difficult todistinguish S1S2 when ascultating, HR106 and 105 = sinus tachy with possible

PACs, BP 117/39 and 128/41


16/18

5/3/2012

Page 16

Identify one priority physiologic and one psychosocial nursing diagnosis for this client. The diagnoses should bestated correctly. Nursing diagnoses should be supported by the assessment data (both subjective and/orobjective) you collected and documented.

State the expected outcomes for each diagnosis. Remember that outcomes should be specific, realistic andobservable or measurable. Include a deadline date for meeting the outcome. Review content in Craven and Hirnleon nursing diagnosis, outcomes, etc.

The nursing interventions need to be individualized, specific and realistic. Each intervention should have afrequency as well (QD at 10 AM, at all times, FYI, Q4H 02, 06, 10, etc.). Be sure to include collaboration andclient teaching, if appropriate.

A colleague should be able to take the care plan and implement it in your absence.

Physiologic ND:NURSING DIAGNOSIS EXPECTED

OUTCOME(S)INTERVENTIONS with

RATIONALE(S)EVALUATION

Include problem,etiology and s/s-(defining characteristicsor as evidenced by )from your assessmentdatamajorcharacteristic(s)

should be present inyour client to qualify.

Impaired gas exchanger/t alveolar-capillarymembrane changesAEB diagnosis ofCOPD and potentialpneumonia infectionresulting fromaspiration events on

xx/xx/xx and xx/xx/xx

Outcomes aremeasurable, realisticand time-limited toyour patient in theacute care. If teaching,what outcome(s) wouldbe necessary?

Xx Will demonstrateimproved ventilationand adequateoxygenation within 7days as evidenced byO2 sat and ventilatorsettings.

Xx will exhibit clear lungfields and remain freeof signs of respiratorydistress within the next7 days.

Interventions should beappropriate to the stated nursingdiagnosis and related to factor.They should be specific and includefrequency of implementation. Besure to include reference the sourceof rationale from NANDA book or

other nursing text.

Monitor RR, depth and effort,including use of accessory muscles,nasal flaring and abnormalbreathing patterns.Rationale:Increased RR, use ofaccessory muscles, nasal flaring,abd breathing and a look of panic inthe clients eyes may be seen with

hypoxia.

Ascultate breath sounds q1-2h. Thepresence of crackles and wheezesmay alert the nurse to airwayobstruction, which may lead to orexacerbate existing hypoxia.Rationale:In severe exacerbationsof COPD, lung sounds may bediminished or distant with airtrapping.

Monitor oxygen saturation

continuously by pulse oximetry.Ratioanale: In oxygen saturation ofless than 90% indicates significantoxygenation problems. The goal ofinpatient therapy for the client withCOPD is to maintain the oxygensaturation greater than 90%.

Were your expectedoutcomes met? If not,would you revise yourEO or yourinterventionsWhy or why not, andwhat would you do

differently?Please use a secondink color if adding orrevising.

Day 1: RR 24/12which means theventilator was set to 12breaths/min but xx wasbreathing 24breaths/min; tidalvolume remainedbetween 350-400, no

use of accessorymuscles, nasal flaringor abnormal breathingpatterns; lung soundsclear bilaterally aftersuctioning; oxygensaturation 96%

Day 2: RR 26/12; tidalvolume remainedbetween 350-400, nouse of accessorymuscles, nasal flaring

or abnormal breathingpatterns; cracklesheard in LUL, RUL,RML, RLL (most likelydue to aspiration event)and clear in the LLL;oxygen saturation 97%.

My outcomes were notmet due to theaspiration event onxx/xx. However, theseare still appropriate


17/18

5/3/2012

Page 17

outcomes for the future.It is hoped that she willbe able to beginweaning off theventilator in the nextfew days and hopefullyher lung fields will clearas she fights the

infection/pneumonia.

Psychosocial ND:NURSING DIAGNOSIS EXPECTED

OUTCOME(S)INTERVENTIONS with

RATIONALE(S)EVALUATION

Include problem,etiology and s/s-(defining characteristicsor as evidenced by )from your assessmentdatamajorcharacteristic(s)should be present in

your client to qualify.

Interrupted familyprocess r/t family rolesshift, shift in healthstatus of familymember, situationalcrises AEB patientshospitalization andinability to care forcognitively impaired

husband

Outcomes aremeasurable, realisticand time-limited toyour patient in theacute care. If teaching,what outcome(s) wouldbe necessary?

Xxs nephew (andtemporary caregiver toher husband) willidentify ways to copeeffectively and useappropriate supportsystems within oneweek.

Interventions should beappropriate to the stated nursingdiagnosis and related to factor.They should be specific and includefrequency of implementation. Besure to include reference the sourceof rationale from NANDA book orother nursing text.

Healthcare staff will develop rapportimmediately with nephew andhusband by providing accurate andtimely information related topatients changing health status.Rationale:Family care can beimproved by focusing on buildingrapport and communicatingproblems and concerns between

families and health professionals.

Involve all family members in thecare, information, and clientteaching session with E.W. whenthey are visiting.Rationale: Family-focused activitiescan help families cope better withthe hospital experience.

Refer xx, her husband and hernephew to appropriate communityresources for assistance (i.e.

support groups, counseling, spiritualsupport, and financial assistance).Rationale:The most importantpredictors of family health werefamily structural factors. It wasfound that the better the familystructure and relationships were,the better the family health was.

Were your expectedoutcomes met? If not,would you revise yourEO or yourinterventionsWhy or why not, andwhat would you dodifferently?

Please use a secondink color if adding orrevising.

Xxs family membersdid not visit while I wasworking on the unit andtherefore I did not getan opportunity to meetthem and establish atherapeutic relationship.However, I still feel theinterventions are crucial

to ensuring the overallwellness of this familyduring a very difficultand uncertain time.

The social worker hasalready referred xxsnephew to resources tohelp in the care of herhusband and in regardsto financial security.

My outcome was methowever it wasimplemented by otherstaff on the unit. Xxsnephew has beenreferred to severalservices.

*ND information obtained from Ackley and Ladwig (xxxx).

12. DISCHARGE PLANNING FOR THIS CLIENT: Include information such as resources, living situation,insurance, community support, support systems, care givers, etc.)


18/18

5/3/2012

Page 18After the latest two aspiration events, xx is far from being discharged from xxxxxx. When the time comes to dischargexx there are many areas to educate her and her family on for continued future wellness. It is important that she andher family members be aware of the signs and symptoms of pneumonia in the elderly. The elderly do not exhibitclassic pneumonia signs. Instead they have symptoms of lethargy, confusion, tachypnea, anorexia or abdominal pain.xx has a long road to recovery ahead of her and she is bound to experience stress and anxiety as she navigates thispath. Therefore it is imperative to encourage her not to return to her previous habit of smoking to relieve that stressand to reinforce the health benefits of not smoking. If home oxygen therapy is recommended, xx. and her familymembers will need to be instructed on how to use the equipment. Lastly, xx. will not be 100% back to her old self

upon discharge and therefore she might be worried about the future of her husband if she cannot provide the samelevel of care she was providing before she became ill. There are resources that provide short-term or long-term carefor her and/or her husband and these options should be presented to them as well as their nephew. If necessary, itwill be important for the social workers to contact these resources and set-up consultation appointments.

13. References used APA format

Ackley, B.J., Ladwig, G.B. (xxxx). Nursing diagnosis handbook: An evidence-based guide to planningcare. X

thedition. St. Louis: Elsevier Mosby.

Craven, R.F., Hirnle, C.J. (xxxx). Fundamentals of nursing: Human health and function. Xth

edition.Philadelphia: Lippincott Williams and Wilkins.

Deglin, J.H., Vallerand, A.H. (xxxx). Daviss drug guide for nurses. 10th

edition. Philadelphia: F.A. Davis.

Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., OBrien, P.G., Bucher, L. (xxxx). Medical -surgical nursing:Assessment and management of clinical problems. X

thedition. St. Louis: Mosby.

Venes, D. (xxxx). Tabers cyclopedic medical dictionary. XXth

edition. Philadelphia: F.A. Davis Company.

Van Leeuwen, A.M., Kranpitz, T.R., Smith, L. (xxxx). Daviss comprehensive handbook of laboratory anddiagnostic tests with nursing implications. X

ndedition. Philadelphia: F.A. Davis.

example of excellent write-up

Documents