Clinical Assessment Form N414

Student Name: Jennifer Sorto Clinical Date: 2/8/19 Assigned Unit:

Thoracic ICU
Age: 74 Gender: Admission date: Resuscitation Status:
F 2/1/19 DNR
Admit weight: 60kg Height: 4’10

Reason for Hospitalization:

Cardiogenic shock with severe mitral valve regurgitation, STEMI with Impella device.

Past medical history:

Lactic acidosis, 3-vessel CAD, STEMI, hyperkalemia, DM type II, pulmonary edema secondary to
hypotension

Past surgical history:

N/A

History of present illness:

Transferred from JVH in cardiogenic shock with severe mitral valve regurgitation, STEMI and Impella
device. TTE showed EF of 57% mild to moderate. Pt remained on triple high dose presser support. BP
continued to drop, O2 fluctuates as low as 83. Echocardiography was completed. Pt has been
unresponsive for 36 hrs and is now in liver and renal failure. Pt passed away at noon and was transferred
to the mortuary.

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 VALUE AND
RECENT EFFECT OF ABNORMAL VALUE
TREND (POTENTIAL SYMPTOMS)
White blood cells 4,500 to 11,000 2/8/19 18.1 (high) Due to sepsis, body is trying to fight of
(WBC) 1046 the infection causes fevers

Red blood cells (RBC) 4.2 – 5.4 2/8/19 1.35 (low) Due to cardiogenic shock, inability of the
1046 heart to pump sufficient blood can cause
hypoxia
Hemoglobin (Hgb) 12-16 2/8/19 4.0 (low) Due to fluid overload and decreased RBC
1046 Can cause hypoxia

Hematocrit (Hct) 35-47 2/8/19 13.1 Fluid overload and blood loss from line
1046 (decreased) placements and placement of impella
Can cause fatigue

TEST NORMAL VALUES DATE/TIME RESULT/ REASON FOR ABNORMAL VALUE AND
RECENT EFFECT OF ABNORMAL VALUE
TREND (POTENTIAL SYMPTOMS)
Platelets 150,000-450,000 2/8/19 81 (low) Due to blood loss from line placements
1046 Can also be lower b/c pt lived in low
elevation
Can cause blood loss
Prothrombin time (PT) 9.5 – 12 sec 2/8/19 27.3 (high) Due to liver failure
1046 Can lead to fluid buildup in legs and
abdomen, can also cause jaundice

International <1.0 2/8/19 2.4 (high) Blood is clotting slower due to low PLTS
normalized ratio (INR) 1046 Can lead to blood loss

Partial thromboplastin
time (PTT)

Sodium (Na) 135-145 2/8/19 151 (high) Due to fluid retention, causes edema
1046

Potassium (K) 3.5 – 5.0 2/8/19 4.6 Normal, K excites the heart with both
1046 high and low values. Can cause
dysrhythmias

Chloride (Cl) 97 - 107 2/8/19 117 (high) Due to dehydration and kidney failure
1046 Can cause acidosis

Glucose 60 - 110 2/8/19 270 (high) Due to DM type II

1046 Can cause fatigue and increased thirst

Hemoglobin A1C

Cholesterol

Blood Urea Nitrogen 10-20 2/8/19 34 (high) Due to renal failure and heart failure
(BUN) 1046 Can have symptoms of weakness and loss
of appetite

Creatinine 0.7 – 1.4 2/8/19 1.15 High side of normal due to kidney
1046 dysfunction and can have symptoms of
decreased urine output
Pre-albumin

Albumin 3.5 - 5 2/8/19 2.4 Normal, can be due to liver failure.

1046 Changes in serum albumin affect total
serum calcium. Very low levels of
albumin can lead to edema, ascites, and
pulmonary edema.

Calcium (Ca) 8.6 – 10.2 2/8/19 7.6 Normal, Can be due to CKD, Calcium
1046 calms and affects nerves and muscles. S/s
of high: can cause bone weakness, n/v
and stomach upset
S/s of low: confusion, memory loss and
muscle cramps

Phosphorus 2.7-4.6 2/8/19 3.5 Normal, Can be due to CKD. S/S of high:
1046 joint pain, muscle pain, diarrhea
S/s of low: irregular breathing, fatigue
and loss of appetite

TEST NORMAL VALUES DATE/TIME RESULT/ REASON FOR ABNORMAL VALUE AND
RECENT EFFECT OF ABNORMAL VALUE
TREND (POTENTIAL SYMPTOMS)
Bilirubin 0.3 – 1.0 2/8/19 3.4 (high) Can be due to anemia, can cause jaundice
1046

Alkaline phosphatase 50 - 120 2/8/19 313 (high) Reflects increased

1046 osteoblastic bone activity and/or liver
disease. Effects can be jaundice, n/v and
weakness.

ALT (alanine 8 - 35 2/8/19 531 (high) Due to liver disease, can cause jaundice
aminotransferase) 1046 and weakness

AST (aspartate 15 - 30 2/8/19 1287 (high) Due to MI can cause hypoxia

aminotransferase) 1046

CK

CK MB

Troponin <.35 2/2/19 164 (high) Due to STEMI, symptom would be

726 hypoxia
B-natriuretic peptide
(BNP)

Other Labs

Arterial Blood Gas

pH 7.35 – 7.45 2/8/19 7.15 (low) Caused by kidney dysfunction. Symptoms
1153 of confusion, fatigue and HA

pC02 35 - 45 2/8/19 29.6 (high) Due to impaired lungs, causes pulmonary

1153 disease.

PaO2 75 - 100 2/8/19 92.6 Normal, Can de due to anemia,

1153 decreased O2 and hypoventilation

HCO3 22 - 26 2/8/19 10 (low) Due to kidney failure, s/s: diarrhea and

1153 vomiting.
Oxygen saturation

Lactic Acid 0.5 – 1 2/8/19 17 (high) Indicator of sepsis, can cause muscle
1153 weakness.

Allergies:
Allergies: NKDA Type of Reaction:

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

Intake/Output:
Diet Order: Restrictions: Precautions: Gag Reflex Intact:
NPO NPO Aspirations Does not have a gag reflex

Appetite (good, fair, Breakfast % Lunch % Dinner %

poor): POOR 0 0 0
 Total Oral Fluid Intake: 0 Total IV Fluid Intake: Total Output: 80 ML
137.2 ML
Enteral Feeding: Rate: Type of enteral feeding tube:
Tropic feed 20 ML/HR Vivonix

Problems swallowing YES Pt is NO

unresponsive
Problems chewing YES Pt is NO
unresponsive
Dentures YES Pt is NO
unresponsive
Needs assistance with YES Pt is NO
feeding unresponsive
**For any questions marked as abnormal, additional detail should be provided for credit

Intravenous Therapy (Continuous infusion)

IV Fluid: Type of Solution IV rate Indication
LR Isotonic 20ML/Hr Maintenance Fluid

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
Left AC 20g IV dressing dry, +4 edema

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)
Right IJ introducer 2 Yes
sheath with/PA cath

Indication for line: Hemodynamic Dressing is dry and intact

monitoring

Central Access (CVC) Site Assessment YES NO

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

Indication for line: Dressing dry and intact

 Arterial Access Site Assessment YES NO
Access site: Dressing dry, +4 edema, Pressure bag
L Brachial inflation volume is 300 mmHg, type of fluid
was NS, confirmation of volume remaining
was unknown, and zeroing of reducer was
completed.
Access site: Dressing dry, no edema, redness of site

**For ALL pressure lines: Pressure bag inflation volume, type of fluid, and confirmation of volume
remaining, and zeroing of transducer is REQUIRED

Elimination:
Last bowel movement: Pt did not have
a BM while in the hospital. Additional comments for abnormal assessment findings:
Constipation YES NO Soft, nontender, nondistended, symmetrical, bowel
Diarrhea YES NO sounds absent in all 4 quadrants.
Flatus YES NO
Incontinence-bowel YES NO
Urinary hesitancy YES NO
Urinary frequency YES NO
Burning YES NO
Incontinence-urinary YES NO
Unusual odor YES NO

Activity:
Type of activity ordered: Ability to walk (gait): Morse Falls scale score:
Bedrest Unable to walk 35

Use of assistive devices:

Cane YES NO Additional comments for abnormal assessment findings:
Crutches YES NO
Unable to walk, pt is unresponsive.
Walker YES NO
Crutches YES NO
Prosthesis YES NO

Physical Assessment Data:

BP: Temp/Method: Pulse: Respiratory rate: SpO2:
98/48 38.7 93 33 92
 Additional comments for any abnormalities:

 If vasopressors are ordered for the patient, note desired goal used for
titration. MAP goal >65
 How did the patient respond to the medication(s)?
Poor response, maxed out on NE & Vasopressor.

Neurological:
Glasgow Coma Assessment *Describe any abnormalities in box below
Eye opening response Score 0
Verbal response Score 1
Motor response Score 1

Additional comments for any abnormalities:

 For any GCS <15, please note specific criteria that was abnormal.
Pt is unresponsive to any stimuli, does not have spontaneous eye opening or
any movement.

Pupil Assessment
Right pupil size Size: 2mm
Left pupil size Size: 2mm
PERRLA YES: NO:
Sluggish

LOC: Does not respond to any stimuli, is not

alert and oriented.

Able to follow commands YES NO

Grip equal, bilateral YES NO
Sensation intact to all extremities YES NO
Speech clear YES NO
Sensory deficit (hearing, vision, taste, smell YES NO
Dizziness, vertigo YES NO
Use of assistive device (glasses, hearing aids) YES NO
Additional comments for abnormal assessment findings:

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

Pacemaker YES NO Specify type (temporary, permanent)

CVP monitoring YES NO Transducer zeroed, pressure bag checked for

fluid/pressure level, no air present
RA pressure

Pulmonary Artery catheter (Swan) YES NO Transducer zeroed, pressure bag checked for
fluid/pressure level, no air present

Additional comments for abnormal assessment findings:

 For patients on ANY IV continuous vasoactive medications for either

[hypotension] OR hypertension, indicate titration range and therapeutic goal.
Vassopreasin 0-3 units/hour MAP goal > 65
Levophed 0-0.4 mcg/kg/min MAP goal > 65

Respiratory: Additional detail

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

Nonproductive cough YES NO

Lungs clear to auscultation, all fields YES NO Weak
Use of oxygen YES NO Specify mode and flow rate of oxygen:
CMV, rate 28

Oxygen humidification YES NO

Smoker YES NO Specify current or past hx:

Additional comments for abnormal assessment findings:

Pt is on ventilator.
Ventilation
Is patient on ventilator? YES NO
Ventilator mode CMV
FiO2 60%
PEEP 8
Rate 28
Tidal volume 270
Type of airway tube ETT
Indication Respiratory distress secondary to pulmonary edema

Is patient requiring non-invasive YES NO Specify type:

ventilation (Bipap or CPAP)?
For all patients receiving mechanical ventilation OR non-invasive ventilation:

 How is the patient tolerating the therapy either mechanical or non-invasive ventilation?
PT was tolerating well, not panicking or showing signs of resistance.
 For mechanical ventilation:
o Was the patient sedated on a continuous IV infusion (s)? List ALL infusions ordered
for sedation.

Versed 2u/hr for rascal of -3 (pt was -5 unresponsive) and sedated.

o Was the patient restrained either with physical restraints or chemically with
paralyzing medications?

Physical restrains

o If the patient was physically restrained, what additional assessments were

completed (including frequency) to ensure that the patient was safe?

Restraint monitoring was completed every 2 hours.

- Assessed for changes in skin breakdown under the restrains
- Restrained R and L upper extremities for vent protocol
- Monitored for injury related to restraints
- Repositioned limbs
- Monitored nutrition and fluid status
- Monitor hygiene
o What additional interventions were taken to help prevent the development of VAP -
(ventilator-associated pneumonia)? Chlorhexadone and oral care was completed.
 For ALL patients:
 Was a bag-valve mask (Ambu-bag) present in the room and easily accessible?
Yes.
 FiO2
IPAP* mmH20
EPAP* mmH20
Rate (For Bipap ONLY)
IPAP-Inspiratory positive airway pressure; EPAP-Expiratory Positive Airway Pressure

Additional detail

Gastrointestinal:
Abdomen soft, nontender, all quadrants YES NO

Bowel sounds present x4 quadrants YES NO Absent in all quadrants

Nausea YES NO
Vomiting YES NO Description:

NG tube YES NO Describe drainage color, amount,

consistency, location of tube:

Problems swallowing YES NO

Problems chewing YES NO
Dentures YES NO
Needs assistance with feeding YES NO
Pt on
tropic
feeds
Stool YES NO Describe amount, color, consistency:

Ostomy YES NO Describe type of ostomy, stoma site and

output:

Additional GI tubes YES NO Specify: Right UQ Billiary drain

Additional comments for abnormal assessment findings:

Pts body was shutting down, bowels were absent in all quadrants.
Urinary:
Continent, voiding without difficulty YES NO Decreased urine output due to renal failure
Incontinent YES NO Interventions:

Foley catheter, patent, down drain, secured YES NO

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

Additional comments for abnormal assessment findings:

For ALL patients with indwelling foley catheters:

 What additional assessments and/or interventions were completed to help in the prevention
of the development of a CAUTI (Catheter associated urinary tract infection)?
-Sterile technique completed upon insertion
-Maintenance of a closed urinary drainage system
-Daily cleansing of the urethra

Musculoskeletal:
Normal muscle tone without weakness YES NO Decreased muscle tone
Able to transfer independently YES NO Pt is unresponsive
Purposeful movement, all extremities YES NO Pt is unresponsive
Normal skeletal alignment/structure YES NO
Altered gait YES NO Pt is not ambulating

Orthopedic device (cast, splint, brace) YES NO Specify

Fall risk YES NO Specify rationale

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

Skin:

Additional comments for abnormal assessment findings:

For ALL patients with impaired mobility:

 Was physical therapy/occupational therapy ordered on the patient? No, due to impella in
groin.
 If present, describe the exercises/activity performed? N/A
 Did the patient tolerate the activity? N/A
 Is there a decline or improvement in the patient’s ability since beginning therapy? N/A

FOR ALL patients:

 Based upon your assessment findings, is your patient at risk for developing skin breakdown?
Yes, pt had rooke boots to prevent breakdown and to improve circulation.
 What additional preventative measures have been implemented or would you anticipate
using to preserve the patient’s skin integrity? I would anticipate changing the pts position
every 2 hrs. I would also make sure that her skin is kept dry to prevent breakdown.

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

Rashes or bruising YES NO Specify location: Bruise on left knee, dark

purple, dry and intact

Sutures, staples, steri-strips YES NO Specify:

Wound drainage YES NO Describe drainage:

Wound drain YES NO Specify:

 Braden Score:
11

Psychosocial and Cultural

Marital status/children/social support: Married/ Has 6 kids / Family for support

Religious preference:
Jehovah’s Witness

Occupation: Retired

Additional comments for abnormal assessment findings:

For ALL patients:

 Was any family/friends present during your shift? Yes, all family members were present.
 Did the family/friends receive any updates on status from the care team (MD, PA, NP)? Yes,
the family had a family meeting with the MD at 11am.
 Was there any specific teaching given (family/friend/patient)? During the conference the MD
first explained the situation, gave rationales and answered all the family’s questions. He used
vocabulary that was simple enough for the family to understand.
 How was the information received? Verbally, through an interrupter as most of the family
was Spanish speaking.

Pain
Pain Score 0 out of 10 (10 being severe pain, 1 minimal pain)

Characteristics Face was relaxed and neutral, absent of movements.

Onset N/A

Location N/A

Duration N/A

Exacerbation N/A

Radiation N/A

Relief N/A

Associated Pt was unresponsive

symptoms
Pathophysiology: Provide a detailed description of the patient’s disease process.
Cardiogenic shock occurs because of the loss of contractile forces in the heart, resulting in left
ventricular dysfunction. This loss of contractile forces can result from mechanical complications
such as papillary muscle rupture, ventricular septal rupture, free-wall rupture with tamponade,
and right ventricular infarction. Mitral regurgitation is the back flow of blood from the left
ventricle to the left atrium. It is caused by a disruption the mitral valve such as ischemia. STEMI
is a class of MI that shows the ST changes on the ECG and has detectable biomarkers in the
circulation due to due to an abrupt reduction in coronary blood flow.

In addition to the disease process, discuss the following items:

Risk factors (if indicated): History of heart attacks and HF along with increased age.

Contributing factors (if indicated): DM, obesity and HTN.

Clinical signs/symptoms: A rapid, thready pulse; a narrow pulse pressure; dyspnea; tachypnea;
inspiratory crackles; distended neck veins; chest pain; cool, moist skin; oliguria; and decreased
mentation.

Complications (possible or actual): Arterial blood gas analysis can reveal a decreased PaO2 and
causes respiratory alkalosis. Hemodynamic findings include a systolic blood pressure less than
85 mm Hg, a mean arterial blood pressure less than 65 mm Hg, a cardiac index less than 2.2
L/min/m2, and a PAOP greater than 18 mm Hg.

Treatment regimen: To minimize myocardial workload and maximize myocardial oxygen

delivery. To improve oxygenation pt was intubated and placed on a mechanical ventilator.
Efforts were aimed toward restoring blood pressure.