Student Name: Dane Woodward Clinical Date: 10/24 Assigned Unit: PCU

Age: 68 Gender: Admission date: Resuscitation Status: Full Code

M 10/23
Admit weight: 150 lb Height: 5’9”

Reason for Hospitalization: Syncope, subacute hemorrhage

Past medical history:

Stroke
Myocardial infarct
Hypertension
Gastric ulcer
Esophagitis
Diabetes mellitus
CVA (cerebral
infarction)

Past surgical history:

Cardiac Surgery

History of present illness: Patient was brought into ED with concerns of stroke. Patient was found in
wheelchair unconscious at rehab center. Was not able to speak for a time, but can speak now with
only some slight slurring.

Clinical Preparation Form N414

Laboratory Values: Complete the table with applicable lab values, for the
results/trend indicate if value is increased or decreased from previous result
TEST NORMAL VALUES DATE/TIME RESULT/ REASON FOR ABNORMAL
RECENT VALUE AND EFFECT OF
TREND ABNORMAL VALUE (POTENTIAL
SYMPTOMS)
White blood cells 3.2 - 10.6 10/24 8.0
(WBC) 10*3/uL @0523

Red blood cells (RBC) 3.58 - 5.26 10/24 3.65(L) Possible bleed, but probably not
10*6/uL @0523 down because of lack of symptoms,
Anemia.
Too low could impair O2
delivery

Hemoglobin (Hgb) 11.6 - 16.0 10/24 9.9(L) Possible bleed, but probably not
g/dL @0523 down because of lack of symptoms,
Anemia.
Too low could impair O2
delivery

Hematocrit (Hct) 34.0 - 46.8 10/24 32.0(L) Possible bleed, but probably not
% @0523 down because of lack of symptoms,
Anemia.
Too low could impair O2
delivery

TEST NORMAL VALUES DATE/TIME RESULT/ REASON FOR ABNORMAL

RECENT VALUE AND EFFECT OF
TREND ABNORMAL VALUE (POTENTIAL
SYMPTOMS)
Platelets 140 - 440 10/24 395
10*3/uL @0523

Prothrombin time
(PT)

International
normalized ratio
(INR)

Partial 25-35 seconds 10/24 32.7

thromboplastin time @0523
(PTT)
Sodium (Na) 136 - 145 10/24 142
mmol/L @0523
Potassium (K) 3.5 - 5.1 10/24 4.4
mmol/L @0523

Chloride (Cl) 98 - 107 10/24 113(H) up Dehydration, kidney

mmol/L @0523 dysfunction
high chloride can cause muscle
weakness

Glucose 70 - 110 10/24 142(H) Diabetes

mg/dL @0523 Prolonged periods of high blood
sugar can lead to vessel damage
and atherosclerosis

Hemoglobin A1C

Cholesterol

Blood Urea Nitrogen 7 - 18 10/24 28(H) up Dehydration, renal impairment

(BUN) mg/dL @0523

Creatinine 0.6 - 1.3 10/24 1.31(H) Dehydration, renal impairment

mg/dL @0523 down

Pre-albumin

Albumin

Calcium (Ca) 8.9 – 10.1 10/24 8.3(L) Dehydration, malnourishment

mg/dL @0523 down Low calcium can interfere with
muscle contractions

Phosphorus

TEST NORMAL VALUES DATE/TIME RESULT/ REASON FOR ABNORMAL

RECENT VALUE AND EFFECT OF
TREND ABNORMAL VALUE (POTENTIAL
SYMPTOMS)
Bilirubin

Alkaline phosphatase
 ALT (alanine
aminotransferase)

AST (aspartate
aminotransferase)

CK

CK MB

Troponin

B-natriuretic peptide
(BNP)

Other Labs

Arterial Blood Gas:

pH

pC02

PaO2

HCO3

Oxygen saturation

Lactic Acid

Allergies:
Allergies: No known Type of Reaction: N/A

Standards of Care:
NO YES INTERVENTIONS ORDERED
DVT prophylaxis X SCD
Stress ulcer prevention X
 Ventilator-associated pneumonia X
(VAP)

Intake/Output:
Diet Order: 1800 ADA Restrictions: Precautions: Gag Reflex Intact:

Appetite: good Breakfast 100% Lunch % Dinner %

Total Oral Fluid Intake: Total IV Fluid Intake: Total Output:

200 mL 700mL 750 mL
Enteral Feeding: No Rate: N/A Type of enteral feeding tube: N/A

Problems swallowing NO
Problems chewing NO
Dentures NO
Needs assistance with YES
feeding

Intravenous Therapy:
IV Fluid: NS Type of Solution IV rate 75mL/hr Indication

IV Fluid: Type of Solution IV rate Indication

Peripheral Access Site Assessment YES NO

IV site and catheter gauge: IV dressing dry, no edema, redness of site X
R hand 20G

IV site and catheter gauge: IV dressing dry, no edema, redness of site

IV site and catheter gauge: IV dressing dry, no edema, redness of site

Central Access (CVC) Site Assessment YES NO

Central line site: # of lumen: Alcohol caps present (if used)

Indication for line: Dressing dry and intact

Central Access (CVC) Site Assessment YES NO

Central line site: # of lumen: Alcohol caps present (if used)
 Indication for line: Dressing dry and intact

Elimination:
Last bowel movement: 10/23

Constipation NO
Diarrhea NO
Flatus YES
Incontinence-bowel NO
Urinary hesitancy NO
Urinary frequency NO
Burning NO
Incontinence-urinary NO
Unusual odor NO

Activity:
Type of activity ordered: Ability to walk (gait): Morse Falls scale score:
Up with assistance Needs assistance

Use of assistive devices:

Cane YES
Crutches NO
Walker YES
Crutches NO
Prosthesis NO

Physical Assessment Data:

BP: Temp/Method: Pulse: Respiratory rate: SpO2:
165/72 36.4 temporal 85 16 98

Neurological:
Glasgow Coma Assessment *Describe any abnormalities in box below
Eye opening response Score
Verbal response Score
Motor response Score

Pupil Assessment
Right pupil size Size: 3mm
Left pupil size Size: 3mm
PERRLA YES: X NO:

LOC: Describe orientation Mostly oriented. Can carry on a conversation, had

 trouble remembering if it was October or November
Able to follow commands YES
Grip equal, bilateral NO Bi lateral weakness, left side contractures
Sensation intact to all extremities YES
Speech clear YES Some slurring
Sensory deficit (hearing, vision, taste, NO
smell
Dizziness, vertigo NO
Use of assistive device (glasses, hearing YES Specify: glasses
aids)
**Additional detail required in box for abnormal findings**

Cardiovascular:
Pulses (radial, pedal) palpable, equal, YES
strong
Normal heart tone (S1, S2), regular YES
Capillary refill (<3 seconds all extremities) YES
Extremity temperature warm to touch, YES
bilateral upper and lower extremities
Edema presence NO Specify location and degree 0-4 scale

Pacemaker NO Specify type (temporary, permanent)

**Additional detail required in box for abnormal findings**

Respiratory: Additional detail

Respiration pattern regular without YES
effort
Use of accessory muscles NO
Productive cough NO
Sputum production NO Description of sputum:

Nonproductive cough NO
Lungs clear to auscultation, all fields YES
Use of oxygen NO Specify mode and flow rate of oxygen:

Oxygen humidification NO
Smoker YES Specify current or past hx: current

Ventilation
Is patient on ventilator? NO
Ventilator mode
FiO2
PEEP
Rate
Tidal volume
 Type of airway tube
Indication

Is patient requiring Bipap or NO Specify type:

CPAP?
FiO2
IPAP* mmH20
EPAP* mmH20
Rate (For Bipap ONLY)
IPAP-Inspiratory positive airway pressure; EPAP-Expiratory Positive Airway Pressure

Gastrointestinal: Additional detail

Abdomen soft, nontender, all quadrants YES

Bowel sounds present x4 quadrants YES Specify: active

Nausea NO
Vomiting NO Description:

NG tube NO Describe drainage color, amount,

consistency, location of tube:

Problems swallowing NO
Problems chewing NO
Dentures NO
Needs assistance with feeding YES
Stool NO Describe amount, color, consistency:

Ostomy NO Describe type of ostomy, stoma site and

output:

Additional GI tubes NO Specify:

**Additional detail required in box for abnormal findings**

Urinary:
Continent, voiding without difficulty YES
Incontinent NO Interventions:

Foley catheter, patent, down drain,

secured to leg
Urine clear, light yellow to amber, no YES
 odor
Additional GU tubes NO Specify

**Additional detail required in box for abnormal findings**

Musculoskeletal:
Normal muscle tone without weakness NO Weak bi-laterally from previous CVA
Able to transfer independently NO
Purposeful movement, all extremities NO Can’t move left side
Normal skeletal alignment/structure NO Left side contrature
Altered gait YES Specify: weak on left side makes walking
somewhat difficult. Is good with walker

Orthopedic device (cast, splint, brace) NO Specify

Fall risk YES Specify rationale: altered gait, connected

to medical equipment

**Additional detail required in box for abnormal findings**

Skin:
Skin dry, intact, color within patient norm YES
Mucous membranes moist YES
Evidence of skin breakdown NO Specify location:

Rashes or bruising NO Specify location:

Sutures, staples, steri-strips NO Specify:

Wound drainage NO Describe drainage:

Wound drain NO Specify:

Braden Score: 18

**Additional detail required in box for abnormal findings**

Psychosocial and Cultural

Marital status/children/social support: None. Patient lives in assisted living facility – has a cat named
Mozart

Religious preference: none

Occupation: retired
Pain
Pain Score ______0______ out of 10 (10 being severe pain, 1 minimal pain)
Characteristics
Onset
Location
Duration
Exacerbation
Radiation
Relief
Associated
symptoms

Medication List
Scheduled

carvedilol (COREG) tablet 3.125 mg : Dose 3.125 mg : Oral : 2 times daily with meals
Mechanism: blocks stimulation of beta adrenergic receptor sites
Indication: Hypertension
Side Effects: Bradycardia, Pulmonary Edema, Angioedema
Implications: Monitor BP, pulse frequently, monitor I/O
Precautions: use cautiously with hepatic impairment, diabetes mellitus

ferrous sulfate tablet 1 tablet : Dose 325 mg : Admin Dose 1 tablet : Oral : Daily with breakfast
Mechanism: enters bloodstream and transported to organs
Indication: iron deficiency
Side Effects: none serious – nausea, constipation, epigastric pain
Implications: assess nutritional status, assess bowel function
Precautions: use cautiously with peptic ulcer disease, ulcerative colitis, alcoholism

gabapentin (NEURONTIN) capsule 100 mg : Dose 100 mg : Oral : 3 times daily

Mechanism: unknown – may affect transport of amino acids across neuronal
membranes and stabilize them
Indication: diabetic peripheral neuropathy
Side Effects: suicidal thoughts, Rhabdomyolysis
Implications: monitor for suicidal tendencies,
Precautions: use cautiously for everyone due to suicidal thoughts

insulin lispro (HumaLOG) injection 1-9 Units : Dose 1-9 Units : Subcutaneous : 4 times daily
with meals and bedtime
Mechanism: translocates GLUT-4 receptors for glucose uptake
Indication: type 1 diabetes
Side Effects: hypoglycemia
Implications: assess for hypoglycemia,
 Precautions: check blood glucose prior to administration, give with food

lisinopril (PRINIVIL,ZESTRIL) tablet 10 mg : Dose 10 mg : Oral : Daily

Mechanism: blocks conversion of angiotensin I to angiotensin II
Indication: hypertension
Side Effects: angioedema, hypotension
Implications: monitor BP, assess for angioedema, monitor CBC periodically
Precautions: use cautiously with hepatic impairment, and with concurrent diuretic
therapy

nicotine (NICODERM CQ) 14 mg/24 hr 1 patch : Dose 1 patch : Transdermal : Daily

Mechanism: provides source of nicotine to prevent withdrawal symptoms
Indication: management of nicotine withdrawal
Side Effects: none serious – skin irritation, pruritus
Implications: assess smoking history, assess smoking withdrawal
Precautions: rotate patch site, contraindicated with recent MI

pantoprazole (PROTONIX) EC tablet 40 mg : Dose 40 mg : Oral : Before breakfast

Mechanism: prevents transport of hydrogens into gastric lumen
Indication: GERD
Side Effects: Pseudomembranous colitis,
Implications: assess for epigastric or abdominal pain, occult blood in stool
Precautions: use cautiously in patients using pantoprazole in high doses for a year or
longer

simvastatin (ZOCOR) tablet 20 mg : Dose 20 mg : Oral : Bedtime

Mechanism: inhibits HMG-CoA which is involved in synthesis of cholesterol
Indication: hypercholesterolemia, dyslipidemia
Side Effects: rhabdomyolysis, memory loss
Implications: obtain diet history especially fat consumption, monitor liver function tests
Precautions: use cautiously with liver disease, alcoholism, renal impairment

PRN

Hydralazine – 10mg – IV
Mechanism: peripheral arteriole vasodilator
Indication: Hypertension
Side Effects: orthostatic hypertension, tachycardia
 Implications: monitor BP and pulse
Precautions: use cautiously in renal, hepatic, cardiovascular, cerebrovascular disease

Pathophysiology:

A subdural hematoma or hemorrhage is where blood collects between the brain and the dura
mater. A subacute hemorrhage refers to the time of the injury. The subacute phase starts 3
to 7 days after the initial injury. The patient was admitted with signs of syncope. The
question is whether the syncope caused the injury, or the injury is now causing syncope.
Clinical manifestations of a subacute hemorrhage include decreased LoC, headache, difficulty
with gait, cognitive dysfunction, personality changes, aphasia. This patient did have gait
difficulties and some difficulty speaking. During the shift he developed very high blood
pressure, 195/86. This was of great concern since he had already had a bleed, this was a huge
risk for another bleed.

References
Lippincott advisor http://advisor-
edu.lww.com/lna/document.do?bid=4&did=525825&