JACKSON COMMUNITY COLLEGE

NUR 171
SUPPORTIVE EDUCATIVE NURSING

PREPARATION FOR SAFE PATIENT CARE

Student Name: Makayla Eppel
Date April 2nd, 3rd

Rev 06.25.2012

DAY ONE PREPARATION - Critical Thinking Summary

Patient Room Number 109 _______
Age 70
_____ M/F Male
___ CODE Status Full __________
Primary Medical Diagnosis Reason for Admission
Acute Respiratory Failure secondary to pneumonia.
Secondary Medical Diagnoses List all that impact patients care
CVA, CKD, HTN
Nursing Care Plan for PRIORITY Physiological Nursing Diagnosis
Nursing Diagnosis in PES
Patient Expected Outcome
Individualized & Prioritized Nursing
Format
(measurable and with time
Interventions with Referenced
Evidence/Rationale
frame)
ASSESS: Auscultate lung sounds q4 hours and
P Ineffective airway clearance
Patient will demonstrate
prn. The
effective
cough and clear lung sounds by presence of course crackles during inspiration
indicates fluid in the airway; wheezing indicates
4/3/15.
E r/t increased secretions, presence
of
tracheostomy

S frequent blood tinged

Patient will maintain a patent

airway
with decreased need for suction
by
4/3/15
Patient will demonstrate
respirations
WNL (12-20) and maintain O2

sputum from tracheostomy

saturation >95% with 30% O2

per
tracheal mask through 4/3/15.

Defining Characteristics Use Ackley

AEB:

text book did you pick the correct

diagnosis?

Absent cough, adventitious breath

Effective expulsion of sputum

with
cough, decreased need for
airway

an
obstruction. (A+L 130)
Monitor ABGs weekly and pulse O2 levels q4 hours
& prn
O2 sats<90% and partial pressures<80 indicate
significant
oxygenation problems.(A+L 130)
TREAT: Administer O2 as ordered. O2
administration
has been shown to correct hypoxemia (A+L 130).
Turn patient q2 hours. Body movement helps
mobilize
secretions and decreases risk of atelectasis,
pooling of
secretions and resulting pneumonia (A+L
130,131).
Suction tracheostomy tube prn. (*hyperoxygenate,
explain procedure and asses for pain, DO NOT suction
>15sec., document)

Hyperoxygenation may help in decreasing risk of

desaturation. Explaining procedure will decrease
anxiety

sounds, changes in respiratory rate

and
rhythm, cyanosis, difficulty
vocalizing,
diminished breath sounds,
excessive
sputum, orthopnea, dyspnea
Can be r/t retained or excessive
secretions secondary to patients
pneumonia, A+L also lists presence
of
an artificial airway as one of the
related
factors.

suctioning, patent tracheostomy

w/o
mucous plugs, auscultation of
clear
lung sounds, respirations 1220bpm,
oxygen saturation >95% and
ease
with respirations.

Suction <15sec to avoid drop in partial

pressure(A+L131)
EDUCATE: Teach client to use controlled coughing
and
deep breathing. Controlled coughing uses the
diaphragm
making cough more forceful and effective(A+L
130)
DISCHARGE: Educate client and family on the
significance of changes in sputum characteristics
as in
color, consistency, amount and odor. This can help
family caregivers to identify early on the signs of
infection and proactively seek medical treatment
before
acute illness occurs (A+L 133)

Potential Complications
If this patients condition were to
worsen, what would be the most likely
reason?
Progression of patients pneumonia
leading an increase in ineffective lung
tissue.

How will you be vigilant in monitoring

for and preventing this complication?
Auscultating lung sounds, assessing work
of breathing, and monitoring VS including
pulse oximetry q4hrs and prn.

What will you do if it happens?

Notify Bill and my primary nurse.

Providing adequate oxygenation per

tracheal mask.
Turning patient q2 to mobilize secretions.
Patient receives regular portable chest XRays.

SCHEDULE
How will you organize your time?

PROCEDURES
What procedures do you have to do?

CARE PATHWAYS
Is the patient on a Care Pathway?

(Report, medications, ambulation, bath,

charting, procedures, etc.)

0645: Report

Be ready! (Catheters, injections, blood

glucose monitoring, dressing changes, etc.)

By 0730: VS.

May require dressing change at chest

tube
site.

By 0900: Assessment completed. Bath

Bolus TF via PEG of fibersource HN 5 cans

completed. Ready to pass meds.

per day. 2 cans @ breakfast, 1 can

@lunch,
and 2 cans @ dinner. Flush with 100ml
H2O
before and after feeds. Pills through PEG.

0900: Meds scheduled to be given.

Rest of day dedicated to paperwork,
procedures, I/Os and progression toward.
outcomes until 1145.Be ready for report
with brains populated by 1200. Report to
primary nurse clinical instructor using
SBAR.

Attach pathway and/or agency PMP.

(What do you need to do Day 1 and Day 2

according to the path or management plan?)

See Kardex

PATHOPHYSIOLOGIES
Primary Diagnosis Pathophysiology Pneumonia
An invading organism triggers an inflammatory response, causing vasodilatation and increased vascular permeability
as well as the activation of neutrophils in hopes of thwarting the ensuing invasion. Fluid that has leeched out of now
hyperpermeable vessels, as well as the neutrophils and the offending organism fill the alveoli, therefore, decreasing
gas exchange. Mucus production is also increased, further obstructing airflow.

Reference Med/Surg or Patho text (less than 5 years old):Lewis Med Surg text 2011
o Textbook S&S
Cough, fever, chills, dyspnea, tachypnea, chest pain. Sputum may be green, yellow, or rust colored (blood-tinged).
Positive blood
cultures, elevated WBCs.
o Patients S&S
Blood tinged sputum. Sputum cultures positive for MRSA. WBCs elevated at 13.4
Secondary Diagnosis Pathophysiology HTN
Hypertension consists of an increase in either cardiac output or increased systemic vascular resistance. This can arise
from a variety of reasons, such as: atherosclerosis, elevated blood lipid/cholesterol levels, stress, vasoconstriction from
caffeine or tobacco use, obesity..etc.. Normal BP should be <120/80, with prehypertension being 121/81-139/89,
hypertension I being at 140/90-159/99 and hypertension II being >160/100.

Reference Med/Surg or Patho text (less than 5 years old):Lewis Med Surg text 2011
o Textbook S&S Asymptomatic, silent killer until hypertension becomes severe and target organ disease occurs.
o Patients S&S: Asymptomatic. BP elevated at 147/83

Secondary Diagnosis Pathophysiology CVA

Ischemia of a portion of the brain due to restricted blood flow. Can be ischemic due to thrombotic, embolic, or
hemorrhagic effects.

Reference Med/Surg or Patho text (less than 5 years old) Lewis Med Surg text 2011
o Textbook S&S: Decreased motor/sensory function, hemiparesis, aphasia, dysphagia, cognitive deficits

o Patients S&S: Decreased swallow, aeb PEG tube, significant cognitive and speech deficits, decreased motor
function.

Use additional sheets as necessary to complete all pertinent medical diagnoses.

MEDICATION SUMMARY
ALLERGIES and usual reaction
NKDA
Generic/Brand
Name and
Class
Heparin Sodium
Heparin
Anticoagulant

Normal Dose

Patients Dose
Times to Give

Drug Action

Why ordered
for this patient?

5000U/1ml

5000U/1ml
Subcutaneous
q12hrs.
0900 2100

Deactivation of
thrombin,
prevention of
conversion of
fibrinogen to fibrin.

hx of CVA, DVT
prophylaxis

Levetiracetam
Keppra
Anticonvulsant

100mg/ml oral
solution
750mg dose.

750mg/7.5ml
PEG
q12hrs.
0900 2100

May inhibit
simultaneous
neuronal firing that
leads to seizure
activity.

hx of seizure
disorder

Make sure
patient is on
another
antiepileptic; not
to be given
crushed

-headache
-anxiety

Decreased
seizure activity.

Mycostatin
powder
Nystatin
Antifungal

1 application
BID prn

1 application
topically
3 times daily
1400 2100
0600

Alters cell
permeability in
fungal cells

Report of groin
excoriation
sores on
scrotum and
penis

S/S of rash or
fungal
infection.
Do not apply to
large open
areas

-rash
-sensitivity

Prevention
of/decrease in
s/s of fungal
infection

Pantoprazole
Protonix
PPI

40mg
suspension

40mg
PEG
Before
breakfast

Proton pump
inhibitor

Decrease risk
of aspiration.

-hyperglycemia
-nausea

Decrease in
acid reflux

Quetiapine
Seroquel
Antipsychotic

25mg

25mg
PEG
before bed
2100

Blocks
dopamine and
serotonin 5-HT2
receptors.

hx of
schizophrenia;
bipolar disorder

Give suspension
in apple juice 30
minutes prior to
food. DO NOT
give in other
liquids
Monitor VS-may
cause
hypotension.

-hypotension
-seizure activity
-hyperglycemia

Valoproic acid
Depakine
Anticonvulsant

200mg/5ml

250mg/5ml
PEG
q12hrs
0900 2100

Faciltates GABA

hx of seizure
disorder

Improved
management of
schizophrenic
and bipolar
symptoms
Decrease in
seizure activity.

Insulin Type

Items to check
before giving;
when to hold
Assess
patients VS,
monitor PTT
hold if patient
is
actively
bleeding

Liver function
test results,
and coagulation
studies.
Watch LOC and
behavior
closely.

Two common
side effects
-hemorrhage
-overly
prolonged
clotting time

-hepatotoxitiy
-depression

You know med

is working
when:
Patients PTT is
therapeutic.

Onset
Peak
Duration

Generic/Brand
Name and
Class
Biscodyl
Dulcolax
Laxative

Normal Dose

Patients Dose
Times to Give

Drug Action

Why ordered
for this patient?

10mg rectal
suppository

10mg
rectal
suppository
every 3 days.

Stimulates
increased
peristalsis

Constipation r/t
feedings or
bedrest

Diphenhydrami
ne
Benadryl
Antihistamine

Normal IVP
dose not found.
But normal
dose 12.5mg.

12.5mg/0.25ml
IVP
prn q6hrs

Competes with
histamine for
H1 receptors

Allergic
reactions

Allergies?
Reaction
severity?
*Push VERY
slowly. May
consider diluting
with 10cc NS

-increased
sedation
-thickening of
bronchial
secretions
*may decrease
Hgb, Hct and
platelet count

Haloperidol
Haldol
Antipsychotic

2mg

2mg/0.4ml
IVP
prn q4hrs

hx
schizophrenia;
bipolar disorder

Monitor VS-may
cause
hypotension

Hydralazine
Apresoline
Antihypertensiv
e

10mg

10mg/0.5ml
IVP
q4hrs prn

Blocks
postsynaptic
dopamine
recptors
Peripheral
vasodilation

hx
hypertension

Check VS. Hold

if systolic
BP>270,
diastolic BP>95
or if patient is
hypotensive.

-dry mouth
-sedation
-increased
seizure activity
-severe
hypotension
-edema

Lorazepam
Ativan
Benzodiazepine

1-4mg

1mg/0.5ml
IVP
prn q6hrs

Potentiates
GABA

Anxiety

Monitor VS
LOC

Morphine
Sulfate
Morphine
Opioid
analgesic

2mg

1mg/0.5ml2mg/1ml
IVP
q2hrs prn

Binds with
opioid
receptors in
CNS.

Severe pain

400-500mg/5ml

PEG
q 3 days prn

Draws water
into intestinal
lumen. Osmotic
laxative.

Constipation

Magnesium
Hydroxide
Milk of
Magnesia
Laxative
Insulin Type
Onset

Items to check
before giving;
when to hold
Last BM?
Abdominal
assessment
Hold if patient is
experiencing
diarrhea

Two common
side effects
-abdominal
cramps
-irritation of
rectum

You know med

is working
when:
Relief from
constipation
aeb BM and/or
verbalized
comfort.
Decrease in
allergic reaction

Decrease in
psychosis
symptoms
Decrease in BP

-drowsiness
-dizzyness
-sedation

Decrease in
anxiety

Assess VS,
including pain
(COLDSPA).
Hold if
RR<10bpm

-CNS
depression
(Respiratory
depression)
-constipation

Decrease in
pain scale

Last BM?
Abdominal
assessment
Hold if patient is
experiencing
diarrhea

-NVD
-abdominal
cramping

Relief from
constipation aeb
BM and/or
verbalized
comfort.

Peak
Duration

LAB VALUES SUMMARY

Diagnosis #1
Diagnosis #2
Diagnosis #3

Medical
Diagnosis
List laboratory and
diagnostic tests
found in your text
for admitting and
secondary medical
diagnoses.

Pneumonia

CKD
BUN,creatinine

HTN

Gram
stain/sputum

CVA
CBC, coag.
studies

culture

electrolytes, BG,

CBC

CBC, WBC diff

Renal and
hepatic
studies, lipid
profile.
CT scan

GFR,
electrolytes,
lipid profile,UA

Renal US

Sphygmomanome
ter

Blood cultures
Chest X-ray
Pulse ox/ABGs

Test
RBC

Hemoglobin

Normal
Value
4.2-5.4
106microL

12.016.0g/dl

ANALYSIS OF LAB VALUES

Admitting
Follow up
date / value date / value
*Admitting
labs
unavailable
due to chart
thinning

Serum lipid profile

Implications
for care

4.01 106
microL 3/19

Cause of
abnormal
finding
CKD.
Decreased
erythropoieti
n
production

10.3g/dl 3/19

CKD

Continue to
monitor.
Administer O2 to
help with
perfusion.
Continue to
monitor.
Administer O2 to
help with
perfusion.

39-50%

35.1% 3/19

CKD

Platelets

150-400,000

390,000

WNL

WBC

411x103/microL

13.4x103/micr
oL
3/19

Infection.

Sodium

134145meq/L
3.5-5mmol/L

138

WNL

4.5

WNL

98108mmol/L

101

WNL

Chloride

BMP

CT scan

Hematocrit

Potassium

Diagnosis #4

Continue to
monitor.
Administer O2 to
help with
perfusion.

Continue to
monitor.
Administer
antibiotics as
ordered.

CO2
Creatinine

2231mmol/L
0.31.5mg/dL

26

WNL
WNL

ANALYSIS OF LAB VALUES Continued

List all other pertinent normal or abnormal lab values.

Test

Normal Value

Admitting
date / value

Follow up
date / value

Cause of
Abnormal
finding

Implications
for care

Coagulatio

*None in

Patient should

chart

have PTT for

Studies
Albumin

heparin therapy!

3.5.5.5g/dL

2.5g/dL 3/27

CKD, possible
protein
deficiency?

Continue to monitor,
make sure patient is
getting adequate
protein in feedings.

BUN

7-22mg/dL

29mg/dL
3/27

CKD

Monitor BUN.
Provide
adequate fluids.

Protein

6.4-8.3g/dL

5.6g/dL 3/23

CKD, possible
protein

Glucose

70-110mg/dL

Continue to monitor,
make sure patient is
getting adequate

deficiency?

protein in feedings.

130mg/dL

No hx of

Continue to

3/27

diabetes noted in

monitor. May

chart. Possible

need HA1C to

med effect from

determine cause

Seroquel

Student Name: Makayla Eppel

Patient Age/Sex : 70, Male

Date: 4/2/2015

Medical Diagnosis: Pneumonia

MENTAL STATUS
LOC and orientation X3
Appearance
Cognition
PAIN
Location, severity, quality, radiation,
duration, precipitating/alleviating
factors, associated symptoms
HEAD AND NECK
Hair and skin
Eyes: sclerae, conjunctivae, pupil
reactivity
Eyes: vision/aids
Ears: lesions, hearing/aids
Nose: symmetry, mucosa, drainage
Mouth: mucosa, tongue, dentation,
lesions
Swallowing/ Appetite
Trachea position
JVD at 45 degrees
UPPER EXTREMITIES
Skin
Pulses
Capillary refill
Strength/ROM
Turgor/edema
CHEST/BACK
Shape
Respiratory effort/SpO2

Code Status: Full

A/O X 1. Oriented to self only. Follows some minimal

commands.
Clean, well groomed
Unable to assess
0/10 using FACE scale. No facial grimacing or signs of
pain.

Hair distributed evenly. Skin intact, no lesions.

Sclera white, conjunctiva pink and moist. PERRLA
Vision adequate, no visual aids.
Ears symmetric, in line with outer canthus of eye, no
hearing aids.
Nose symmetric. Nasal mucosa pink and moist, no
drainage.
Buccal mucosa pink and moist, tongue midline. No
lesions.
NPO.
Midline.
No JVD @ 45 degrees.
Skin pink, warm and dry. Intact.
Radial pulses +2 and equal bilaterally.
Brisk <3seconds. Nailbeds pink.
Unable to assess. Does not follow commands.
Turgor < 4 seconds. No edema.
AP to transverse ratio 1:2.
Resps. with ease, respiratory rate 17. SpO2 96% (6L
30%O2 TM)

Cough/sputum

Productive cough. Light green sputum with blood tinged

specks from trach

Lung sounds anterior and posterior

Skin condition/integrity
Heart sounds

Lung sounds clear, but diminished in bases bilaterally.

Skin, pink warm and dry. Intact.

Apical pulse rate/rhythm (auscultate

full min)
ABDOMEN/PERINEAL AREA
Contour, symmetry
Bowel sounds in 4 quadrants
Tenderness
Urinary pattern/color
Bowel pattern/character/last BM
Perineum (if appropriate)

85bpm. Strong and regular.

LOWER EXTREMITIES
Skin color/integrity

Heart sounds strong and regular. S1S2. A: S2>S1, P: S2>S1,

E:S1=S2, T: S1>S2 M:S1>S2

Soft, rounded. Symmetric.

Bowel sounds active X 4.
Non-tender, no guarding
Foley catheter in place. Clear amber urine.
Incontinent of bowel. Last bowel movement 3/27.
Groin reddened and excoriated, small sores on scrotum
and penis.
Skin pink, warm and dry. Wound on right ankle open to air.

Refer to pictures in chart.

Edema
Pulses
Capillary refill
Strength/ROM
EQUIPMENT
Pumps
Tubes
DURING SHIFT
Vital signs/time

No edema noted.
Dorsalis Pedis +1 and equal bilaterally
Capillary refill brisk <3 seconds
Leg muscles atrophied. Unable to assess.
N/A
PEG, Tracheostomy, PICC placed in left upper arm.

BP: 147/83, HR: 85, RR: 17, T: 98.4, SpO2: 96% (0730)

Blood glucose monitoring

results/insulin

N/A.

Intake and output

320cc H2O flushes per PEG; 300cc clear amber urine in

foley.
2 cans of Fibersource given at 0900.
N/A
BUN 29. Albumin 2.5. Total protein 5.6.
Uknown.
Patients cognition compromised, unable to complete.

Food intake/Appetite/Nausea
IV solution and rate/hourly checks
Significant lab results
Support system/SO involvement
Patient education completed

NURSING DIAGNOSIS
Ineffective Airway Clearance r/t increased secretions, presence of tracheostomy a.e.b frequent
blood tinged sputum from tracheostomy

SOAP NOTE (on above nursing diagnosis only)

S-Patient non-verbal secondary to mental illness and CVA.
O- Vitals stable, apical pulse 85bpm, BP 147/83, RR:17, SpO2: 96%, T: 98.4. No pain. Heart
sounds strong and regular, bowel sounds active X4, abdomen soft, rounded and non-distended.
No edema. Skin intact besides wound on right ankle, to be left open to air (refer to pictures on
patients chart). Lung sounds clear but diminished in bases, productive cough with light green
sputum. Patient required suctioning X2. Suctioned moderate amount of light green, blood tinged
sputum. Patient now respirating with ease.
A-Patient progressing toward discharge.
P-Continue nursing care plan

END OF SHIFT CHECK-OUT

Patient safe and comfortable

Meds administered

Reported off to RN

and instructor
I&O documented
______________________________

MAR signed

Student signature

DAY TWO PREPARATION

EVALUATION
Did you choose the appropriate nursing diagnosis for Day One?

Yes

No

What would have been a better choice?

Were your objectives and interventions appropriate?

Yes

No

What would have been more appropriate?

Nursing Care Plan for SECOND PRIORITY Nursing Diagnosis
Nursing Diagnosis in PES Format
Patient Expected Outcome
Individualized & Prioritized Nursing
(measurable and with time
Interventions with Referenced
Evidence/Rationale
frame)
1.Assess site of skin impairment to determine
P Impaired skin integrity
Patient will regain integrity of
skin
cause. The cause of the wound must be
surface prior to discharge.
E r/t impaired mobility secondary to
CVA,
atrophied extremities, incontinent
bowel, bedrest with impaired bed
mobility.

Patient will show no signs of

further skin breakdown prior to
discharge

S aeb stage 3 pressure ulcer to right

lateral malleolus and calf,
lesions on scrotum and penis
Defining Characteristics (from book
did you pick the correct
diagnosis?)
Destruction of skin layers;
disruption of
skin surface; altered
epidermis/dermis.

AEB: Skin intact, with no signs

of
development of pressure ulcers
or lesions.

determined
before appropriate interventions can be
implemented
(A+L, 735 2011)

2. Inspect and monitor site of skin impairment

at least once a day for color changes, redness,
swelling, warmth, pain, or other signs of infection.
Pay special attention to high-risk areas Systematic
inspection can identify impending problems early
(A+L, 736 2011)
3.Utilize a skin protectant to protect skin in
perineal area from exposure to acidic conditions
from
stool incontinence. Implementing this measure
can
significantly decrease skin break down and
pressure
ulcer formation. (A+L, 736 2011)
4. Do not position client on the side of skin impairment.

Reposition client every 2hrs. with care to protect against

adverse
effects of mechanical forces such as pressure, friction and
shear.
Do not position client directly on a pressure ulcer. Continue to
turn
/reposition the individual regardless of support surface in use
(A+L, 736 2011)

Student Name: Makayla Eppel

Date: 04/3/15

Patient Age/Sex: 70, Male

Medical Diagnosis: Pneumonia

MENTAL STATUS
LOC and orientation X3
Appearance
Cognition
PAIN
Location, severity, quality, radiation,
duration, precipitating/alleviating
factors, associated symptoms
HEAD AND NECK
Hair and skin
Eyes: sclerae, conjunctivae, pupil
reactivity
Eyes: vision/aids
Ears: lesions, hearing/aids
Nose: symmetry, mucosa, drainage
Mouth: mucosa, tongue, dentation,
lesions
Swallowing/ Appetite
Trachea position
JVD at 45 degrees
UPPER EXTREMITIES
Skin
Pulses (brachial, radial)
Capillary refill
Strength/ROM
Turgor/edema
CHEST/BACK
Shape
Respiratory effort/SpO2

Code Status: Full

A/O X 1. Oriented to self only. Follows some minimal

commands.
Clean, well groomed
Unable to assess
0/10 using FACE scale. No facial grimacing or signs of
pain.

Hair distributed evenly. Skin intact, no lesions.

Sclera white, conjunctiva pink and moist. PERRLA
Vision adequate, no visual aids.
Ears symmetric, in line with outer canthus of eye, no
hearing aids.
Nose symmetric. Nasal mucosa pink and moist, no
drainage.
Buccal mucosa pink and moist, tongue midline. No
lesions.
NPO.
Midline.
No JVD @ 45 degrees.
Skin pink, warm and dry. Intact.
Radial pulses +2 and equal bilaterally.
Brisk <3seconds. Nailbeds pink.
Unable to assess. Does not follow commands.
Turgor < 4 seconds. No edema.
AP to transverse ratio 1:2.
Resps. with ease, respiratory rate 20. SpO2 97% (6L
30%O2 TM)

Cough/sputum

Productive cough. Light green sputum with blood tinged

specks from trach

Lung sounds anterior and posterior

Skin condition/integrity
Heart sounds

Lung sounds clear, but diminished in bases bilaterally.

Skin, pink warm and dry. Intact.

Apical pulse rate/rhythm (auscultate

full min)
ABDOMEN/PERINEAL AREA
Contour, symmetry
Bowel sounds in 4 quadrants

91bpm. Strong and regular. Telemetry: normal sinus

rhythm.

Tenderness
Urinary pattern/color
Bowel pattern/character/last BM
Perineum (if appropriate)

Heart sounds strong and regular. S1S2. A: S2>S1, P: S2>S1,

E:S1=S2, T: S1>S2 M:S1>S2

Symmetric, slightly distended.

Bowel sounds active X 3, hypoactive in right lower
quadrant.
Non-tender, no guarding upon palpation
Foley catheter in place. Clear amber urine.
Incontinent of bowel. Last bowel movement 3/27.
Groin reddened and excoriated, small sores on scrotum
and penis. Selan cream and mycostatin powder to
excoriated area.

LOWER EXTREMITIES
Skin color/integrity
Edema
Pulses (femoral, popliteal, PT, DP)
Capillary refill
Strength/ROM
EQUIPMENT
Pumps
Tubes
DURING SHIFT
Vital signs/time

Skin pink, warm and dry. Wound on right ankle open to air.
Refer to pictures in chart.

No edema noted.
Dorsalis Pedis +1 and equal bilaterally
Capillary refill brisk <3 seconds
Leg muscles atrophied. Unable to assess.
N/A
PEG tube in LUQ, foley catheter, tracheostomy, PICC
line in left upper arm.
Apical HR 91, BP 108/78, RR 20, T 98.4, SpO2: 97% (6L
30% O2 per
tracheal mask) (0725)

Blood glucose monitoring

results/insulin

N/A

Intake and output

300cc flushed through PEG, Output: 375cc through

foley.
NPO. 2 cans fibersource given @ 0730.
N/A
BUN 29. Albumin 2.5. Total protein 5.6.
Uknown.
Patients cognition compromised, unable to complete.

Food intake/Appetite/Nausea
IV solution and rate/hourly checks
Significant lab results
Support system/SO involvement
Patient education completed

NURSING DIAGNOSIS
Ineffective Airway Clearance r/t increased secretions, presence of tracheostomy a.e.b frequent
blood tinged sputum from tracheostomy
SOAP NOTE (on above nursing diagnosis only)
S-Patient non-verbal secondary to mental illness and CVA.
O-Vital signs stable: apical HR 91, BP 108/78, RR 20, T: 98.4, SpO2: 97% (6L 30% O2 per tracheal
mask). Cardiovascular assessment negative. Heart sounds strong and regular, S1S2. Telemetry:
NSR. Lung sounds remain diminished in bases, cough remains productive with light green
sputum. Suctioned patient X2, copious amounts of light green and blood tinged sputum. Bowel
sounds active X3, hypoactive in RLQ, abdomen slightly distended. LBM 3/27. Pressure ulcer on
right lateral malleolus and calf continues to be open to air, bilateral ankles supported with air
boots.
A-Patient progressing toward discharge.
P-Patient to be discharged at 1400 today.

END OF SHIFT CHECK-OUT

Patient safe and comfortable

Meds administered

Reported off to RN

and instructor
I&O documented
______________________________

MAR signed

Student signature