Student Name

Date of Care Care of the Adult PatientClinical Worksheet

Patients Initial Date of Admission

Room

Age

Sex

Code Status

Nurse

Admitting Diagnosis COPD exacerbation Respiratory Failure

Patient Data
Reason for this hospitalization, recent surgeries and secondary diagnoses: Other Health Concerns/Past Medical History/Allergies

Dyspnea Acute Bronchitis

Cigarette Smoker

Killian Jameison Diverticuli, 1.5 cm pulmonary nodule in middle right lobe constipation surgery: tonsillectomy
Barriers/Cultural Considerations (example: deaf, blind, indigent, etc.) NA

Kardex/Chart Information Vital Signs: q weekly Activity: bedrest w/ bathroom privaleges Hygiene: with assist Diet/Tube Feeding & Why: regular AccuCheck: NA I/O: NA Urinary Catheter: NA IV Site & Fluid: NA

Tubes/Drains: NA Oxygen : 3L nasal canula Ancillary Services: OT/PT/Speech therapist/ Southern Care Hospice Risk for Falls: Low / High Why?: High/ weak, oxygen tubing, dyspnea Risk for Skin Breakdown: Low / High Why?: High/ ordered bedrest Treatment /Procedures/Equipment: Nebulizer treatments, O2 therapy monitor Oxygen saturation q shift

Date and Time/Head to Toe Assessment and Documentation 04/09/13 0730 Received report from instructor and assumed care....,ITSN 0820 patient reports pain 10/10. HR:98,RR:14,lungs clear. Administer Duoneb 5mg w/ Morphine ER 30mg w/ 2mL NS. ,ITSN 0825 HR:96 RR:16. Pt received morning meds from student nurse.., ITSN 0840 patient reports pain 7/10. HR:106,RR:18, lungs: slight wheeze....,ITSN 0900 patient consumes 50% of breakfast......., ITSN 0930:VS: T. 97.1, HR.98, RR.18, BP.119/70, O2.92% 3L NC. AA&O x 3. PERRL 3mm.Patient stated concerned about not having a BM since Saturday. Abdomen: soft, tender, hyperactive x 4. UE: strength 5/5 equal bilaterally, cap refill < 3 sec. Skin: barrel chested, warm, pink, and dry. Normal turgor. Radial pulses strong, equal bilaterally @ 3+. Torso: S1 & S2 audible. No murmurs noted. Apical pulse 106 and correlates with radial pulse. Lungs: slight wheeze noted in right middle lung on expiration. Acute dyspnea upon any movement. Full assist with hygiene. LE: strength 5/5 equal bilaterally, cap refill <3 sec. Skin: pink, warm, & dry. Safety: bed low, wheels locked, bed-side table and call light within reach, ITSN 1030:full assist patient to wheel chair and to scales to be weighed. Weight: 56.4kg. full assist patient back to bed. Safety: bed low, wheels locked, bed-side table and call light within reach,ITSN 1130: Safety: bed low, wheels locked, bed-side table and call light within reach, ITSN 1200: patient reports pain 10/10. HR:98 RR:14, lungs slight wheeze in middle right lobe, administer Duoneb 5mg w/ Morphine ER 30mg w/ 2mL NS..,ITSN 1205 HR.82, RR. 18 ....,ITSN 1230 HR.100, RR. 16, lungs clear. Patient reported pain 7/10. Safety:bed low, wheels locked, bed-side table and call light within patient reach.,ITSN 1300 patient consumed 50% of lunch. Safety:bed low, wheels locked, bed-side table and call light within patient reach..,ITSN

1335: Gave report and relinquished care to LPN...,ITSN

Most Current Lab/X-rays/Diagnostics: List those completed, normal ranges, and results. Explain any abnormalities). List all ordered labs pertinent to patients current admission.

Lab

Normal Range NA NA NA NA NA

RBC WBC Hbg. Hct. Platelets WBC Differential:

Neutrophils Eosinophils Basophils Lymphocytes Monocytes

Patient result NA NA NA NA NA

Clinical Picture (patient specific) NA NA NA NA NA

NA 1-4 NA 25-33 NA

NA 9H NA 15 L NA

NA Pulmonary infiltrates NA Insufficient T cell production ratio vs chronic conditions (respiratory failure, pulmonary nodule, emphysema, hypoxia) NA

Chemistry Panel: Na+ (Sodium) K+ (Potassium) Cl - (Chloride)

CO2 (CarbonDioxide) BS Blood Sugar

NA
NA NA NA

NA
Na

BUN

(Blood Urea Nitrogen)

NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Cr (Creatinine) Bilirubin (total) Total Protein Albumin Ca+ (Calcium) Cholesterol Triglyceride LDL HDL Chol / HDL ratio Alk Phos AST, SGOT ALT, SGPT

NA
NA

NA
NA

NA NA NA NA NA NA NA NA NA

Lab

Normal Range

Patient result

Clinical Picture (patient specific)

Cardiac Enzymes:
CPK mass CKMB Troponin I C-Reactive Protein Homocysteine
BNP

NA 0-3ng/ml NA NA NA
NA

NA 8H NA NA NA NA

NA Respiratory failure (damage to the lung) NA NA NA NA

Coagulation Labs
PT APTT INR NA NA NA NA NA NA NA NA NA

Urine:
Specific gravity pH Protein mg/dl Glucose mg/dl Ketone mg/dl Bilirubin Blood Urobilinogen Leukocyte esterase Nitrite NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA

Other Labs:
RDW PO2 11.5-14.5 75-105mmHg 14.6 H 113 H Iron deficient anemia Nasal cannula

Diagnostic Tests: 1/26/13 Chest x-ray lungs expanded with no infiltrate emphysematous changes, irregular opacities bilateral Compatible with scarring and nodules.

3/27/13 CT- chest no pulmonary embolism 1.5cm pulmonary nodule in right middle lung.

Describe Problem/Disease and Etiology

Chronic Obstructive Pulmonary Disease is characterized by chronic inflammation found in the airways, lung parachyma, and blood vessels. Irreversible airflow limitation during forced exhalation caused by loss of elastic recoil and airflow obstruction caused by mucus hypersecretion, mucosal edema, and bronchospasm. Inability to expire air is a main characteristic of COPD. The peripheral airways become obstructed, air is progressively trapped during expiration. The chest hyperexpands and and becomes barrel shaped as the respiratory muscles are not able to function effectively.

List signs and symptoms of the disease/condition Symptoms of cough, sputum production, or dyspnea, and/or a history of exposure to risk factors for the disease. A chronic intermittent cough usually occurs in the morning and may or may not be productive of small amounts of sticky mucus. Dyspnea is often progressive and usually occurs with exertion. In late stages of COPD, dyspnea may be present at rest. Wheezing and chest tightness may be present but may vary by time of the day or from day to day, especially in patients with more severe disease. Fatigue is a prevalent and affects the patients activities of daily living.