Student Name: Corinthia Huckins

Clinical Form 1: DATA COLLECTION/ ASSESSMENT

Patient’s Initials: Room/unit number Advanced Directives: Age __73_____

None
JJ ICU - 2 M or F
POA- Daughter

Dates of patient care Admission date: Allergies and reaction: Staff RN:

January 28th 2019 January 23rd 2019 Lisinopril- facial edema Mirely

Chief complaint: SOB

Date of surgery:

Patient’s primary concern/ medical diagnosis: Acute hypoxic respiratory failure

Surgeries done this admission (if applicable): N/A

Current medical diagnoses (include chronic conditions such as diabetes, COPD).

1. HTN 2. Positive C-Diff 3. DM 4.CKD 5. Chronic anemia

Other Medical Diagnosis: Metabolic acidosis, SOB, Pulmonary Edema,

Paraplegic -1973 due to GSW

Ht: 157cm Wt: 45 kg BMI: Nutrition

18.15
Wt Orders: N/A

VS Ordered Frequency: Q1hour Diet Order and why receiving: NPO , due to ET
tube and medical sedation.

Dob Hoff Placed: - 1/28/19 @ 1400

Admission or Baseline Vital Signs:
Oral Fluid Order: N/A
Temp: 37.3 c
Blood Glucose Monitoring: Q6
RR: 11
Swallowing Problems: N/A projected consult
HR: 90 ordered after extubating

BP:158/89 Last BM : 10/27 – Liquid x2

O2: 88-100 RA – 3L BiPap

Respiratory Tubes

Oxygen Order/Vent Chest Tube Y or N Foley: Yes NG Y or N

Settings: A/C
Orders: N/A JP :No Orders: Dobhoff
Peep: 5 ordered 1/28/19 p EGD

FIO2: 40% Placed: 1/28/19 @ 1400

SpO2: 95% Incentive Spirometer: Hemovac: N/A Feeding Tube Y or N

N/A
PIP: 16 Other: Type: Dobhoff

Mean airway pressure: Orders: p EGD

7.2
Placed 1/28/19
TV: 300

O2 Sat Order:

Activity Dressings

Orders: Q 2 Turns Assistive devices: WC Dressing Orders: Right IJ, daily

PUP Lower coccyx, PRN

TEDS: No SCDs: Yes Type of dressing: Sterile Central line

Foam

Glasses: No Hearing Aids: No Location of dressing: Right IJ

Lower coccyx

Dressing appearance: CDI ( clean, dry, intact)

CDI – removed, no longer needed

Intravenous/ Fluid status Other Information

IV sites/ Date inserted: R forearm 20g – 1/27/19
Right IJ, triple lumen – 1/24/19
Site appearance: CDI, 20g flushed properly
Scheduled diagnostic tests: EGD, Dialysis, CXR,
EKG
Labs to be checked during your shift: ABG, Aptt
, H&H, Troponin, Sputum sample

Ordered fluids/rate: 0.9% 250mL 20mL/hr

Consults done: EGD ( GI) , Wound,
Strict monitoring of I&O
Speech ( reevaluate after extubating)

I&O last 24 hours: Intake= 950 Output=735

I&O your shift (required): Intake: 400 Output:

100
Student Name:

Clinical Form 1: DATA COLLECTION/ ASSESSMENT, CONTINUED

What is your learning outcome with this client? My learning outcome with this patient is too properly
and knowledgably care for an intubated patient with multiple drips. Time management with medications,
patient care, and the interdisciplinary team.

What will your assessment focus on? My assessment of this patient will focus on room safety (clear
path, labeled and properly running medications, and patient safety), proper ventilation (ABC), heart and
lungs sounds, and skin care with ROM. Vital signs monitored closely due to current intubated state and
history of high blood pressure. On the given patient I would focus mainly on the cardiovascular,
peripheral vascular and the respiratory systems.

REVIEW OF SYSTEMS/SUBJECTIVE DATA

General Survey Patient skin was CDI, no rash, ecchymosis. Skin is warm dry and intact, normal skin
turgor.
(overall appearance,
hygiene, dress, skin Pt is thin with an cachectic appearance, family at bedside did hygiene care.
color, body structure,
behavior, facial Pt is intubated, medically sedated with a RASS of -2
expressions)

Vital Signs 0800- VS: RR-16 BP-163/66 Map- 89 HR-63 Temp- 36.8 internal O2 Sats: 99%
vented Pain: N/A. Stable with a trending up BP
(TPR, BP, MAP, Ht, Wt,
BMI) 1200 VS RR-16 BP-158/59 Map- 92 HR-76 Temp- 36.8 internal O2 Sats: 99%
vented Pain: N/A. Stable with BP controlled

Ht: 157cm Wt: 45 kg BMI: 18.15

Pain Pt is intubated, medically sedated. No signs of agitation or being uncomfortable

(OLDCARTS/PQRST)

Psycho-Social Status Pt has support system at bedside that includes two daughters who work in the
medical field. Patient has yet to be alone since intubated. Several visitors throughout
(Support system, the day. Sisters reported pt memory was intact before intubation along with her
psychological health, functional judgement. Family states patient was a chronic marijuana user. Sister
patterns of coping, stated that her mother has always been a fighter and always fought to pull through.
defense mechanisms,
culture, religious/spiritual
beliefs, socioeconomic
concerns)

Mental Health LOC= lethargic, medically sedated. Response to painful stimuli

(Affect, behavior, Pt stated on admission that she felt safe at home

suicidal ideation, safety)

Integumentary System

Skin
(color, temp, moisture,
turgor, m/m, integrity,
wounds (size, COCA,
tissue color), dressings,
tubes, drains
Patient skin was CDI, no rash, ecchymosis. Skin is warm dry and intact, normal skin
turgor.
Oral care q2hr
Braden score of 12, patient at risk for pressure ulcer
Wound consult was ordered. Doctor examined on rounds. Patient had a bad biopsy 7
years prior that left a deep scar. Wound fully healed with no complication at this
time.

Hair Thin, white

(color, density,
distribution)

Nails Nail beds pink with < 2 sec capillary refill

(Color, thickness,
hygiene)

Neuro System

(Primary) RASS- admission = 2+ Current= 2- Goal= 0

(LOC, orientation, GCS, Patient medically sedated.

Pupils (size and PERRL),
Extrem. Strength and L -1 R-1 pupil
sensation, speech, gait Glasgow scale= 8

(Secondary and PRN) Patient medically sedated. No abnormal neurological signs for patient’s state. Face
symmetric
(Vision, EOMs, Corneal
reflex,
Nystagmus)(Facial
Expressions, sensation,
strength; swallowing, gag
reflex, tongue
movements)(Pronator
drift, Romberg test,
babinski’s sign,
dermatomes)

HEENT None

(Bleeding, drainage, Heparin D/C RBC =2

lesions, other
abnormalities)

Neck Supple, symmetrical, trachea midline, no JVD

(Neck vessels, lymph IJ clean and intact

nodes, thyroid, etc.)

Breasts No anormalités

(Lesions, nodules,
drainage, etc)

Cardiovascular System

Heart S1 & S2 regular rate , sinus rhythm

Systolic murmur heard near RUSB ( right upper sternal border)

(S1, S2; S3/S4/murmur; Daily EKG

reg vs, irreg.; heart rate
& rhythm, Rub)

Peripheral Vasculature No edema present

(rate, rhythm, and quality Contracted lower extremities

of peripheral pulses (0-
4); cap refill; edema +2 radial pulses bilateral
(pitting(rate [+1 - +4)] vs +2 pedal pulse bilateral
generalized)

Respiratory System AC vented patient. Medically sedated. No signs of distress

(Body position, rate, Wheezing

rhythm, depth, signs of
resp distress [e.g. R lower lobe coarse crackles
accessory muscle use, L lower lobe diminished
pursed lips, nasal flaring,
retractions], Pt currently smokes marijuana
cough/sputum (COCA),
Smoking hx,
immunizations; shape,
symmetry chest wall
movement, lung sounds
ant and post bilat

Gastrointestinal System Hospital acquired C-Diff last No BM 24hr prior

(Skin, guarding/splinting, ABD soft no rigidity noted, no distention,

shape/contour, N/V/D,
Dysphagia, bowel habits, Bowel sounds present in upper abd, absent in lower abd
last bm, bowel sounds X
4 quads, results of
palpation, masses?,
rebound tenderness and
location, drainage
devices (NGT,
colostomy, ileostomy),
tube feeds, etc

Genitourinary System Foley placed 1/24/19

(Urinating, incontinence, Prior 24hr – 10mL per hour

urine (color, amount,
odor, turbidity), Current shift – 20mL per hour
catheter/type, urinary sx?

Male N/A

(testicular pain/edema,
penile d/c,
itching/burning,
lesions)

Female Foley care performed. No signs of infection.

(LMP, urethral/vaginal
d/c, itching/burning,
lesions)

Musculoskeletal System Paraplegic, Contracted lower extremities

(Height, posture, spine, PUP pressure ulcer prevention includes q2hr turns
wounds, joints, ROM,
injuries, inflammation, Poor overall muscle tone
muscles [tone, strength,
size, tremors], distal Thin
CSMs Adequate ROM

Time (baseline/ Admission) Time (0800) Time (1200)

VS: RR-11 BP – 158/89 Map- VS: RR-16 BP-163/66 Map- 89 VS RR-16 BP-158/59 Map- 92
112 HR-90 Temp-37.3 HR-63 Temp- 36.8 internal HR-76 Temp- 36.8 internal

O2 Sats: 88-100 RA O2 Sats: 99% vented O2 Sats: 99% vented

Pain: 5/10 Pain: N/A Pain: N/A

Cultural practices and beliefs that might influence the plan of care.

Family present at bedside stated they are catholic. They did not have any concerns about upholding any
practices or beliefs.

Sister did mention her mother had a bad experience with a previous intubation and was not sure she ever
wanted to do that again. During this stay she stated it was okay as a life saving measure.

Could this patient benefit from an interdisciplinary consult? Why or why not? Yes, patient will need
many consults such as speech, OT and PT when she extubated. During her current state she will benefit
from RT consults for her respiratory and nutritional consults due to the emaciated and anemic state while
being NPO.
List your top three priority nursing diagnoses on this patient. Explain your rationale using one of the
priority setting models (ABCs, Maslow, etc.).

1. Impaired Spontaneous Ventilation related to respiratory muscle fatigue as evidenced by

alteration in metabolism, history of COPD and dyspnea, alteration in respiratory rate,
pattern and diminished breath sounds when trial breath was performed and on assessment.
To provide/maintain ventilator support
Always a top priority when caring for a patient.
Rationale: ABC (airway breathing circulation) because that is what circulates oxygen to the vital
organs and keeps the patient alive.
2. Caregiver Role Strain related to duration of caregiving, unpredictability of care situation and
care recipients health status as evidenced by caregiver fatigue, patient stating concern about
family member, decisional conflict and spiritual distress.
To enhance caregiver’s ability to deal with current situation
Rationale: Maslow Hierarchy of Needs covers many levels of the pyramid with caregiver role
strain for both the patient and the family. Physiological and safety needs are met. Love and
belonging and Esteem for both parties involved. Self-actualization for the care giver. Each of these
levels is addressed in care and discharge planning.
3. Ineffective Airway Clearance related to presence of artificial airway as evidenced by dyspnea,
alteration in respiratory rate and pattern and diminished breath sounds.
To mobilize secretions
Rationale: ABC (airway breathing circulation) done to preserve a patent airway, develop wellbeing
and ease of breathing, improve pulmonary ventilation and oxygenation, and to avoid risks related
with oxygenation problems

Clinical Form 2: PATHOPHYSIOLOGY

Acute hypoxic respiratory failure results when one or both of these gas-exchanging functions are

inadequate ( e.g., insufficient O2 is transferred to the blood or inadequate CO2 is removed from the

lungs). (Lewis, Bucher, McLean, & Harding, 2017, p. 1609). Hypoxemic respiratory failure is also

referred to as oxygenation failure because the primary problem is inadequate O2 transfer between the

alveoli and pulmonary capillaries. Hypoxemic respiratory failure is commonly defined as a PaO2 less

than 60 mm Hg when the patient is receiving an inspired O2 concentration of 60% or more). (Lewis,

Bucher, McLean, & Harding, 2017, p. 1609). Four physiologic mechanisms may cause hypoxemia and

subsequent hypoxemic respiratory failure: mismatch between ventilation (V) ventilation and perfusion
(Q), referred to as V/Q mismatch; shunt; diffusion limitation and alveolar hypoventilation (Lewis,

Bucher, McLean, & Harding, 2017, p. 1610). In JJ state she experiences VQ mismatch due to underlining

disease processes. She came in reporting SOB but had experienced a myocardial injury due to

hemorrhagic shock related to her GI bleed. Hypovolemic shock respiratory failure usually describes

patients who are intubated and ventilated in the process of resuscitation for shock. The purpose of

ventilation is to have gas exchange become stable and to unload respiratory muscles, lowering their

oxygen consumption. Hypovolemic shock is due to lack of blood circulating the body; this is a result of JJ

GI bleed, anemia, and pulmonary edema.

Hypovolemic shock is inadequate perfusion of tissues and cells from loss of circulatory fluid

volume (Potter, Perry, Stockert, & Hall, 2016, p. 1291). Lack of perfusion to tissues and major organs

causes the body to not maintain homeostasis. When tissues and organs lack the oxygen they need they

suffer and this lead to many other disease processes and complications. One of the first to respond to the

depletion of oxygen is going to be the heart that needs it to pump and circulates it to the rest of the body.

In JJ case heart failure did not seem to be the main focus of her care. Her heart seemed to sustain damage

due to the lack of circuiting oxygen.

Pulmonary Edema is an abnormal accumulation of fluid in the alveoli and interstitial space of the

lungs (Lewis, Bucher, McLean, & Harding, 2017, p. 529). The lungs get filled with serosanguinous fluid,

which is fluid that contains blood. This again relates back to JJ hemorrhagic shock and hypovolemia upon

admission. Pulmonary edema is usually a complication from heart disease or lung disease. In JJ case her

uncontrolled hypertension could be leading her into heart failure. The stress on JJ organs is causing a lack

of homeostasis in the body and in return, her organs have to compensate in other ways. She is presenting

with shortness of breath due to fluid and amount of work her lungs have to put in to oxygenate properly.

Shortness of breath medically termed dyspnea. Dyspnea is associated with hypoxia. It is the

subjective sensation of difficult or uncomfortable breathing. Dyspnea is shortness of breath usually

associated with exercise or excitement, but in some patients, it is presented without any relation to activity

or exercise. It is associated with many conditions such as pulmonary disease cardiovascular disease,

neuromuscular condition, and anemia (Potter, Perry, Stockert, & Hall, 2016, p. 881). This is a common

finding in patients with pulmonary edema, acute hypoxia, shock, and heart disease.

Diabetes mellitus – is a chronic multisystem disease characterized by hyperglycemia related to

abnormal insulin production, imparted insulin utilization or both (Lewis, Bucher, McLean, & Harding,

2017, p. 1120). Here lies one of the main underlying causes for all other cascading events in JJ health.

The body needs to break down glucose to make energy, in JJ case she does not control her diabetes

allowing the body to no utilizes the glucose “energy”. This again causes the body to not maintains

homeostasis and use other sources within the body for energy such as fat. Fat usage produces ketones

which are acidic. Diabetes leads to HTN and heart failure. When the body has to work harder because of

the high acid levels and cannot maintain homeostasis many body functions become overworked or

depleted of their needs.

Chronic kidney disease involves progressive, irreversible loss of kidney function (Lewis, Bucher,

McLean, & Harding, 2017, p. 1075). This is directly related to her uncontrolled DM, HTN. It also directly

results in metabolic acidosis. Metabolic acidosis results from the kidneys’’ impaired ability to excrete

excess acid and from defective reabsorption and regeneration of bicarbonate (Lewis, Bucher, McLean, &

Harding, 2017, p. 1077). The kidneys cannot filter the acid in the body anymore and lead the body to

metabolic acidosis. CKD is also responsible for her chronic anemia because of decreased construction of

erythropoietin by the damaged kidneys’.

Chronic anemia is a deficiency in the number of erythrocytes (red blood cells), the quantity or

quality of hemoglobin and or volume of packaged RBC (hematocrit). The kidneys’ are the main producers

of erythrocytes and in JJ case she has CKD which makes her production much lower. The body does not

maintain homeostasis due to this. It is a prevalent condition with many diverse causes such as blood loss,
impaired production of erythrocytes, or increased destruction of erythrocytes. (Lewis, Bucher, McLean, &

Harding, 2017, p. 607) Because of RBCs transport O2, erythrocyte disorders can lead to tissue hypoxia.

Decrease RBC production is what accounts of JJ chronic anemia; a decreased erythropoietin does not

allow her to produce enough RBC. A cardiopulmonary manifestation of severe enema result from

additional attempts by the heart and lungs to provide adequate amounts of O2 to the tissues, Cardiac

output is maintained by increasing the heart rate and stroke volume. (Lewis, Bucher, McLean, & Harding,

2017, p. 608) The low viscosity of the blood contributes to the development of systolic murmurs and

bruits. This helps explain a possible reason for JJ systolic murmur. On admission, JJ noted a bowel

movement with frank blood visualized and hemoglobin dropped to 4.8. Along with the low production of

RBC, GI bleed and pulmonary edema JJ body went into hypovolemic shock due to the low amount of

circulation blood, which carries oxygen.

Hypertension and coronary artery disease are primary risk factors for heart failure (Lewis, Bucher,

McLean, & Harding, 2017, p. 737). Hypertension is a consistent elevation of systemic arterial blood

pressure. Persistent SBP > 140mm Hg and DBP > 90 mm Hg. (Lewis et al., 2012). The exact cause is

unknown but has many contributing factors, such as elevated sodium-retaining hormones and vaso-

constricting substances that cause narrowing of the vessels and occlusion to produce high pressure to

maintain blood flow, alcoholism, diabetes mellitus etc. (Lewis et al., 2012). Complications include heart

failure, myocardial injury, stroke, and coronary artery disease. JJ DM and lifestyle most likely lead to her

hypertension. She in uncompliant with her DM treatment which in return means she probably does not

follow a strict diet. She is also paraplegic which puts her at greater risk due to the lack of physical

activities she might perform. Hypertension can cause damage to many different organs in the body due to

the fact that it lessens the amount of blood (which carries oxygen) or blocks blood flow. Hypertension

puts a lot of stress on the body and causes it to overwork and be depleted. The body can only keep up with

that for so long be for it wears out.

 C-Diff which is Clostridium difficile causes impaired absorption by destroying cells, causing

inflammation in the colon and produce toxins that cause damage (Lewis, Bucher, McLean, & Harding,

2017, p. 930). The risk for c-diff is high in the hospital and for patients taking antimicrobial drugs.

Patients in the ICU have additional risk factors due to the fact they are usually on a drug that suppresses

gastric acid. This fits the patient in multiple categories, her c-diff is related to her hospital stay and her

current drug regimen. Her body has not sustained homeostasis and her body has not been able to obtain

her good flora. She has responded to Flagyl very well.

References

Lewis, S. M., Bucher, L., McLean, H. M., & Harding, M. M. (2017). Medical-surgical

nursing: Assessment and management of clinical problems (10th ed.).

Potter, P. A., Perry, A. G., Stockert, P., Hall, A., & Ochs, G. (2017). Fundamentals of Nursing.

St Louis: Elsevier
Student Name:
Clinical Form 3: Weekly Medication List
Medication: Name
(Generic/Trade), Class
(Therapeutic and
Pharmacologic), Dose, Route,
Times, Onset, Peak, Duration
Nicardipine – Calcium channel
blocker – antihypertensive
5mg/hr IV (initial dosage)
O: within min
P: 45 min
D: 50+ hr
Clinical Course Pack – NUR 347L
Pharmacologic actions and
Indication for/Action on this
patient
Management of
hypertension and angina
pectoris
Inhibits the transport of
calcium into myocardial and
vascular smooth muscle
cells
Systemic vasodilation
resulting in decrease BP
Allergies: Lisinopril
Common Side Nursing Care: Was this Drug
Effects/Life Effective for your
Threatening Side 1. Assessment and Patient? Be Specific
Effects interventions(ie, lab
monitoring, vitals)
2. Teaching
3. Administration (ie,
compatibilities, interactions)
Peripheral edema, 1. Monitor BP, Pulse, EKG, Yes, blood pressure
Arrhythmias, HF, Intake and output, weight, was being addressed
Steven-Johnson signs of heart failure, but not fully
syndrome (SJS) angina, rash (SJS) controlled. After
administration my
2. If patient was not sedated patient was not
or tell the bedside family- experiencing blood
monitor or report abnormal pressure that was as
VS, avoid grapefruit juice, high as the previous
may cause dizziness,
reading. Patient was
protect self from sun. Teach on multiple
about HTN interventions medications that could
3. Dilute. Caution when help lower BP. It is
giving with fentanyl unclear if this was
hypotension may occur. working directly or in
Beta blockers may result in conjunction with other
meds.
14
 bradycardia.

Fentanyl- Sublimaze- Opioid Analgesic supplement to
analgesics - 50mcg/hr ( general anesthesia. Balanced
1mcg/kg) – IV – anesthesia
O: 1-2 min Binds to opiate receptors in
the CNS altering the
P: 3-5 min response to and perception
D: 0.5 -1 hr of pain. Decrease pain
Confusion, delirium 1. Monitor RR, BP. May Yes, patient was
drowsiness, apnea, increase serum amylase and sedated and the dose
laryngospasm, lipase. Watch for matched her weight.
arrhythmias, respiratory depression, The patient did not
bradycardia, hypotension, arrhythmias show any signs of
respiratory distress, distress or pain.
2. If patient was not sedated
hypotension.
or tell the bedside family-
monitor or report abnormal
VS, avoid grapefruit juice,
may cause dizziness,
explain sedation to the
family

3. Do not give with MAO.

Dilute with D5W or 0.9%
NaCl – this must be done
slowly

Propofol - Diprivan – General Induction of general
anesthetics - 5mcg/kg/kr – IV anesthesia and maintenance
of balanced anesthesia.
O: 40sec Sedation of intubated,
P: unknown mechanically ventilated
patient in and ICU.
D: 3-5 min
Short-acting hypnotic
mechanism of action is
unknown. Produces amnesia.
Induction and maintenance
Dizziness, HA, 1. Asses RR, BP, Pulse,
Apnea, bradycardia, maintain airway, asses level
hypotension, burning, of sedation, CNS function
pain, stinging, should be monitored and
propofol infusion tested daily, propofol
syndrome, fever infusion syndrome ( severe
metabolic acidosis,
hyperkalemia, lipemia,
rhabdomyolysis,
hepatomegaly, cardiac and
Yes, patient was
sedated. Patient did
not show any signs of
distress or pain. Stable
VS for current state of
disease.

Clinical Course Pack – NUR 347L 15

 of anesthesia renal failure)

2. Explain sedation to the

family and that this might
cause amnesia. If patient
was not sedated or tell the
bedside family- monitor or
report abnormal VS.

3. Initial dose- additional

dose over 5-10 min until
response is achieved. Dose
must be evaluated every
24hr. Can only be diluted
with D5W. Change IV lines
every shift. Allow 3-5 min
between dose adjustments.

Labetalol -Trandate – Management of Fatigue, weakness, 1. Monitor BP pulse- q15 Not in current state.
antianginals, antihypertensive, hypertension dry eyes, arrhythmias, after IV dose, I&O, weight, Blood pressure was
beta blocker bradycardia, CHF, May increase BUN levels, being addressed but
Blocks stimulation of beta1 ( pulmonary edema, increase glucose level not controlled. Patient
10mg – IV- myocardial) orthostatic was on multiple
hypotension, erectile 2. If patient was not sedated medications that could
O: 2-5 min Decrease BP or tell the bedside family-
dysfunction help lower BP. It is
P: 5 min monitor or report abnormal unclear if this was
VS. Cannot skip dose. working directly or in
D: 16-18 hr Glucose monitoring very conjunction with other
important meds.
3. Caution when given with

Clinical Course Pack – NUR 347L 16

 general anesthesia

Ocular lubricant – Artificial Provides lubrication and Photophobia, lid 1. Asses eye for foreign Yes, this medication
tears - protection in a variety of edema stinging, body before application. lubricated the eye due
conditions. Keep eye transient blurred Monitor for dryness to the sedation that did
Lacri-lube SOP ophthalmic lubricated due to sedation vision, eye discomfort not allow patient to
ointment 2. If patient was not sedated self-lubricate their
or tell the bedside family own eye
1 app both eyes Q4H that this is to lubricate the
O: immediately eye

P: N/A 3. May alter effects of other

concurrently administered
D: N/A ophthalmic medications.
Asses eye before
application

Pantoprazole – Protonix-
antiulcer agents – proton-pump
inhibitors- 40mg IV push
O:15-30 min
P: 2hr
D: unknown
Erosive esophagitis Clostridium difficile- 1. Asses for blood in stool. Yes, but not without
associated with GERD. associated Diarrhea, Monitor lab functions such side effects. This PPI
Maintenance of healing of headache as liver function test and has helped prevent
erosive esophagitis. magnesium. gastric ulcer but has
not helped with
Binds to an enzyme in the 2. If patient was not sedated patients C-diff ( risk
presence of acidic gastric or tell the bedside family to vs. reward)
pH, preventing the final monitor and report any
transport of hydrogen ions abnormal stools
into the gastric lumen
3. Administer over two
minutes.

Clinical Course Pack – NUR 347L 17

Vancomycin -Vancocin – Treatment of potentially life-
Antibiotic – anti-infective- , threating infections when
125mg/5mL – IV less toxic anti-infective are
contraindicated.
O: Rapid
Binds to bacterial cell wall,
P: end of infusion resulting in cell death
D: 12-24 hr
Aspirin – Salicylates- Inflammatory disorders
antipyretics, nonopiod including: rheumatoid
analgescis – salicylates- 81mg arthritis and osteoarthritis.
once daily - PO Mild to moderate pain.
Prophylaxis of transient
O:5-30 min ischemic attack and MI.
P:1-3 hours Produce analgesia and
D: 3-6 hr reduced inflammation and
fever by inhibiting the
Clinical Course Pack – NUR 347L
Ototoxicity, 1. Monitor urinary output, Yes, it is efective,
nephrotoxicity, chills, also monitor trough of WBC trend was
fever, rash, phlebitis, drug, temp and skin, BP, lowering. Medication
anaphylaxis, Culture first. CBC. Monitor was helping fight
hypotension for anaphylaxis ( rash, infection.
pruritus, laryngeal edema,
wheezing) Asses bowl
sounds
2. If patient was not sedated
or tell the bedside family
why the medication is
being given
3. Make sure to have
culture before given if
ordered. Monitor IV site
closely. Toxicity trough
should not exceed
10mcg/mL
GI bleeding, 1. Asses for rash during Yes, Labs within
dyspepsia, epigastric therapy, monitor hematocrit limits that would not
distress, nausea, and blood loss alert discontinuing this
exfoliative dermatitis, medication and no
stevens-johnson 2. If patient was not sedated signs of clotting or MI
syndrome, toxic or tell the bedside family to
epidermal necrolysis, avoid concurrent use of
alcohol, to report any signs
anemia, anaphylaxis
of rash or blood in stool.
Take/administer dose
18

Metronidazole- Flagyl- anti-
infective, antiprotozoal,
antiulcer agent- 500mg/100ml
Q8H -IV
O: Rapid
P: End of infusion
D: 6-8 hours
Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2016). Davis's Drug Guide for Nurses (15th ed.). Philadelphia, PA: F.A. Davis.
Clinical Course Pack – NUR 347L
production of
prostaglandins.
Decreases platelet
aggregation
Decreased incidence of
transient ischemic attacks
and MI
Treatment of anaerobic
infections, inta-abdominal
infections, anti-infective
associated clostridium
difficile associated diarrhea
Disrupts DNA and protein
synthesis in susceptible
organisms
prescribed.
3. Confirm chewable tablet
is being used due to the fact
you cannot usually crush
and this medication needs
to be crush to administer to
a sedated patient.
Seizures, dizziness, 1. Asses for infection ( VS, Yes, patient had not
headache, aseptic urine, stool, WBC) obtain had a loose, mucus,
meningitis, culture and sensitivity foul smelling bowel
encephalopathy, abd before giving, Asses for movement during
pain, anorexia, rash. shift.
nausea, phlebitis at IV
site. 2. If patient was not sedated
or tell the bedside family to
report any rash, urine may
be very dark,
3. Infusion stable for 30
days at room temp. Do no
put in fridge. Administer
premixed solution.
19
Student Name:

Clinical Form 4: LAB/DIAGNOSTIC TESTS

RED = HIGH BLUE =LOW

Diagnostic test Normal Range Client’s Results & Why do you think this test result Nursing Implications
Date of Test is abnormal for this patient
(Analysis)?
Is the lab trending
up or down?

Date #1 Date #2

1/27/19 1/28/19

Chemistries/

Metabolic Panel

Na 135 – 145 mEq/l 142 143 Steady Continue to monitor

K 3.5 – 5.0 mEq/l 3.6 3.1 Trending down Assess S&S of hypokalemia,
arrhythmias, vertigo, NVD,
monitor ECG and notify HCP
if abnormal dysrhythmias
appear

Continue to monitor

Glucose 75-110 g/dl 161 76 Trending down -> Steady Continue to monitor

History of uncontrolled DM

Clinical Course Pack – NUR 347L 20

Cl 97 – 107 mEq/l 109 107 Trending down-> Steady Continue to monitor

CO2 23 – 29 mEq/l 19 23 Trending up -> Steady Continue to monitor, trending

important– normal symptoms
Check for presence of metabolic include deep, vigorous breath
acidosis or alkalosis. Pt presents and flushed skin. Pt breathing
in a acidotic state due to being controlled by ventilator.
metabolic acidosis, severe
diarrhea, dehydration, acute renal
failure

BUN 8 – 21 mg/dl 104 55 Trending down Keep pt. hydrated-stay away

from fluid deficit and excess.
High-antihypertensive agents can Patients with a diagnosis of
elevate BUN. BUN values also CHF are held to a fluid
tend to rise as the person ages restriction of 1500-2000 ml per
because nephrons tend to day .The goal for a Pt. with
decrease. BUN can also increase CHF would be to decrease
in the presence of renal disorder fluid retention because that’s
because urea is formed as an end usually a problem. Monitor
product of protein metabolism urine output report less than
and is exerted by the kidney. 25mL/hour. Monitor VS for
Digested blood from GI bleeding increase pulse, decrease BP,
is a source of protein and can increased RR ( patient is
also cause elevation. Increased controlled on vent). Monitor
levels also caused by renal fluid intake (IV) to output
failure secondary to heart failure, hypervolemia can lead to
DM, acute MI pulmonary edema. Continue to
monitor

Creatinine Male 0.6 – 1.2 mg/dl 3.77 2.71 Trending down Notify physician of noted
values and take down orders as
Female 0.5-1.1 mg/dl High-if BUN and Creatinine are to what he wants us to do next

Clinical Course Pack – NUR 347L 21

 elevated it is a high possibility
that renal disorder is present
An elevated Creatinine is also
common in patients with CHF.
Creatinine is high due to kidney
injury and inefficient filtering
and myoglobin metabolism in
HF
Calcium 8.2 – 10.2 mg/dl 8.2 8.0 Trending down
Diarrhea and malabsorption of
calcium form GI tract due to GI
bleed and c-diff. renal failure
causes phosphorus retention.
Magnesium 1.6 – 2.6 mg/dl 2.0 1.6 Trending down
Phosphorus 2.5 – 4.5 mg/dl 6.1 3.3 Trending down
High can mean that pt. is has
renal insufficiency. Because
BUN, Creatinine, and
Phosphorus are all elevated I
Clinical Course Pack – NUR 347L
concerning the elevated values.
The elevated value may be a
result of CHF. Continue to
evaluate. Monitor urine output
Continue to monitor
Continue to monitor
Phosphorus and calcium
usually tend to trend according
to each other. Low calcium can
result in cardiac issues and
tetany. Trend and report any
drop or hypocalcemia
symptoms (tetany, tremors,
chvostek’s or trousseau’s
signs) Monitor ECG for
prolonged ST segments and
lengthened QT intervals.
Continue to monitor
Remember sample must be
sent within 30 of draw.
Phosphorus and calcium
usually tend to trend according
to each other
22
 suspect a renal problem. Continue to monitor

Bilirubin (Total) 0.3 – 1.2 mg/dl .3 .2 Trending down Continue to monitor

Pt has hx of chronic anemia Don’t shake tube after draw to

prevent hemolysis.

Protein (Total) 6.0 – 8.0 g/dl Not ordered or drawn

Albumin 3.4 – 4.8 g/dl 2.7 2.4 Trending down Continue to monitor

Acute liver failure and renal Edema common due to fluid

disorder. shifts form the vascular fluid to
the tissue spaces implement
Malnutrition ( patient is thin with measures to avoid skin
an cachectic appearance) breakdown.

Hematology-CBC

WBC 4.5 -11 x 103/mm3 6.5 9.8 Trending Up Continue to monitor

Determines presence of infection Report abnormal levels,

( MI, acute infection, monitor VS and temp.
inflammation)
Elevated temp could indicate
further infection, also observe
wounds for additional redness,
draining or swelling.

Patient is not currently out of

normal limits but is trending up
and needs to me monitored
closely with her history and

Clinical Course Pack – NUR 347L 23

 current diagnosis

Differential WBC
Count

Bands/Stab (%) 3-6 Not ordered or drawn Not main focus of care

Segs/Polys (%) 50-62 Not ordered or drawn Not main focus of care

Eosinophils (%) 0-3 Not ordered or drawn Not main focus of care

Basophils (%) 0-1 Not ordered or drawn Not main focus of care

Lymphocytes (%) 25-40 .2 .9

Monocytes (%) 3-7 .1 .5

RBC Male 4.71-5.14 x106/mm3 3.6 2.94 Trending down Continue to monitor

Female 4.20-4.87 Decrease in RBC is tied to RBC is related to circulation of

x106/mm3 kidney dysfunction. O2 in the blood and needs to be
Erythropoietin which stimulates trended and watched carefully.
red blood cell production is Decreases in RBC need to be
made in the kidney reported.

Hemorrhage for GI bleed

RBC Indices

MCV 82-98 mm³ 85fl

MCHC 32-36 g/dl 33.3 34.3 Steady Continue to monitor

Indicates the myoglobin RBC is related to circulation of

concentration per unit volume of O2 in the blood and needs to be
RBC. Shows adequate trended and watched carefully.

Clinical Course Pack – NUR 347L 24

 concentration resulting in Decreases in RBC need to be
hypovolemia reported.

MCH 26-34 pg/cell 29.3 High-can be a further indicator Continue to monitor

of anemia – chronic diagnosis
Weight of hemoglobin common
with anemia is high reading
RBC is related to circulation of
O2 in the blood and needs to be
trended and watched carefully.
Decreases in RBC need to be
reported.

HGB Male: 13.2-17.3 g/dl 10.5 8.6 Trending down Continue to monitor

Female: 11.7-15.5 g/dl Hemoglobin is composed of iron Patient has hx of anemia

which transports oxygen. common finding. Needs to be
Common in patient with anemia, trended and reported when
kidney disease, and hemorrhage trending down. Check HCT

HCT Male 43-49% 31.5 25.1 Trending down Continue to monitor – report if
trending low or bleeding is
Female 38-44% Volume of packed red blood found
cells.
Asses for bleeding and blood in
Common low in pt with anemias stool
and on antibiotics
Patient is on antibiotics and has
a hx of anemia common to find
this result.

PLT 150 – 450 x 103 / µl/mm3 159 160 WNL

Coagulation Panel

PT 10-13 seconds 12.9 High Continue to monitor- Report if

trends up
Prothrombin is synthesized by

Clinical Course Pack – NUR 347L 25

 the liver and is an inactive
precursor in the clotting process.
Major use of the PT is to monitor
anticoagulant therapy
Patient on the high side of
normal but not an urgent
concern. This is expected with
drug therapy aspirin which the
patient has been prescribed.

Monitor for signs or symptoms

of bleeding

Vit K antidote

INR Ther: x2.0-3.0 1.1 Low - may be due to her recent Continue to monitor
MI due to hypoxia
Valve: x2.5-3.5

APTT 25-39 seconds Not ordered or drawn

Cardiac Studies

Total Creatine Kinase 0-120 µg/mL 108 Steady – CK can show if Continue to monitor
(CK) elevation of troponin is
myocardial or skeletal muscle
injury.

CK-MB 0-3 µg/mL Not ordered or drawn

CK index 0-3 Not ordered or drawn

Myoglobin <55 µg/mL Not ordered or drawn

Troponin < 0.4µg/mL Not ordered or drawn

Troponin I <0.35 µg/mL 12.12 9.8 Trending down- Patient Continue to monitor
presented with acute hypoxia and
resp failure. The heart sustained Trending down do to corrected
a lack of 02 for a period of time hypoxia with intubation. The

Clinical Course Pack – NUR 347L 26

 cause injury. Troponinema (heart heart is not being starved of
injury not related directly to MI oxygen.
but a comorbidity)

Myocardium injury and unstable

angina

Troponin T <0.2 µg/mL Not ordered or drawn Troponin 1 was ordered for
assessment of cardiac muscle
injury

Serum Lipids These were not drawn. Pt has hx
of uncontrolled hyperlipidemia. I
anticipate the reasoning to be
that it was not the current
problem and medications were
already on board for care of
CAD
Continue to monitor Labs need
to be drawn once other
diagnosis are controlled to
check that current meds are
working and sufficient

Cholesterol <200 mg/dL Not ordered or drawn

Triglycerides <150 mg/dL Not ordered or drawn

HDL 60 mg/dL or above Not ordered or drawn

LDL <100 mg/dL Not ordered or drawn

Other Cardiac Tests

C-reactive protein <1.0 mg/dL Not ordered or drawn

BNP <100 pg/mL Not ordered or drawn

Clinical Course Pack – NUR 347L 27

Arterial Blood
Gases

pH VBG 7.35-7.45 7.88 7.42 Trending down-> Steady Continue to monitor

This trend is concurrent Shows if pt is reverting back to

with mechanical ventilation. acidosis or is trending towards
Helps the body achieve alkalosis
homeostasis
Direct link- very important to know
if the body is compensating and in
which direction

PaCO2 VBG 30-40 mmHg 41.3 Co2 retention Continue to monitor

This is concurrent with a Shows if pt is reverting back to

patient who is acidotic. acidosis or is trending towards
Carbon dioxide can’t escape alkalosis respiratory or metabolic
due to alveolar damage

HCO3 VBG 18-23 mEq/l 21.2 23.7 Trending up Continue to monitor

This is concurrent with a Shows if pt is reverting back to

patient who is recovering acidosis or is trending towards
form metabolic acidosis alkalosis

Mechanical ventilation has Sign of lactic acid building up, helps

helped maintain balance pH
homeostasis

PaO2 VGB 80-95 mmHg 90.8 Stable due to mechanical Continue to monitor
ventilation. Amount of

Clinical Course Pack – NUR 347L 28

 oxygen available Shows if pt is reverting back to
acidosis or is trending towards
alkalosis. Important to know how
much oxygen the patient is receiving

Urine Tests No urine analysis was UA should be sent if urinary tract

ordered. Anticipate infection symptoms present.
reasoning to be that this was
not the current problem or
diagnosis at the time of
admission.

pH 5.0-9.0 Not ordered or drawn

Specific gravity 1.010- 1.025* Not ordered or drawn

Protein Negative Not ordered or drawn

Glucose Negative Not ordered or drawn

Ketones Negative Not ordered or drawn

Leukocyte Esterace Negative Not ordered or drawn

WBC Less than 5/hpf Not ordered or drawn

RBC Less than 5/hpf Not ordered or drawn

Bacteria None Not ordered or drawn

Kee, J. L. (2014). Handbook of Laboratory and Diagnostic Tests with Nursing Implications (9th ed.).

Other lab tests:

Cultures:

Radiology/Other Diagnostic reports:

Clinical Course Pack – NUR 347L 29

ECG- Sinus rhythm with anterolateral T wave changes suggestive of LVH repolarization

CT ABD/ Pelvis – unremarkable, severe atherosclerosis

EGD- Rule out Ulcer - Negative, feeding tube ordered

Clinical Course Pack – NUR 347L 30

Clinical Form 5: Nursing Care Plan Diagnosis
NURSING DIAGNOSIS
WITH
SUPPORTING DATA
Impaired Spontaneous
Ventilation related to
respiratory muscle fatigue as
evidenced by alteration in
metabolism, history of
COPD and dyspnea,
alteration in respiratory rate,
pattern and diminished
breath sounds when trial
breath was performed and
on assessment
Clinical Course Pack – NUR 347L
DESIRED OUTCOMES
LTO: Patient will reestablish
and maintain effective
respiratory patter via
ventilator with absence of
retractions or use of
accessory muscle, cyanosis
or signs of hypoxia before
extubating in two weeks’
time
STO: Patient will remain
free of dyspnea or
restlessness during my shift
STO: Patient will participate
in efforts to wean within
individuals ability in the next
5-7 days
INTERVENTIONS WITH EVALUATION OF
DESIRED OUTCOMES
RATIONALE WITH
SUPPORTING
OBSERVATIONS
(REVISIONS PRN)
I: The nurse will explain the intubation and -Outcome not met during
mechanical ventilation process to the client and my shift. Patient progresses
family as appropriate during shift or PRN but was still highly sedated
and VBG were trending
R: Explanation of the procedure decreases toward stable ventilation.
anxiety and reinforces information (p. 841). Continue plan of care
Even if client is sedated it has been shown that
they can still hear and remember -Outcome met and in
progress during my shift
I: The nurse will assess for secure endotracheal patient showed no signs of
tube auscultate bilateral breath sounds to confirm
distress or restlessness.
placement on initial assessment and PRN Continue plan of care
R: Auscultation alone is not enough to check -Outcome in progress but
placement but is vital to verify every shift (p. no progression during my
841). X-ray is also used for placement but shift. Patient had VBG that
breath sounds are a first line of knowing were stabilizing but trial
placement breathing was unsuccessful.
I: The nurse will ensure that ventilator setting are Continue plan of care
estimated goal date may
31
 appropriate to meet the clients ventilation need to be pushed.
requirement or delegate this task to appropriate
staff during shift

R: Ventilator settings should be adjusted to

prevent hyperventilation or hypoventilation (p.
841). These setting should be checked against
the order

I: The nurse will check that monitor alarms are

set appropriately at the start of each shift

R: This action benefits client safety (p. 841)

Client safety is number one priority

I: The nurse will respond to ventilator alarms

promptly

R: Common causes of high pressure alarm

include secretions, condensation in the tubing,
biting of the endotracheal tube, and
compression of the tubing. Low pressure
alarms include ventilator disconnection, leaks,
and changing compliance (p. 842).

I: The nurse will drain collected fluid form

condensation out of ventilator tubing as needed

R: This action reduces the risk of infection by

decreasing inhalation of contaminated water
droplets (p. 842).

I: The nurse will administer analgesics and

sedatives as needed to facilitate client comfort

Clinical Course Pack – NUR 347L 32

 and rest continuously during the shift

R: Clients getting mechanical ventilation

requires sedation to help reduce the anxiety,
pain and agitation that accompany this
intervention (p. 842).

I: The nurse will initiate a sedation vacation with

lightening of analgesics and sedatives until the
client becomes awake. During this carefully
monitor the patient and protect them from harm
once daily

R: Sedation vacation have been associated

with decreased length of intubation and
decreased incidence of ventilator- associated
pneumonia (p. 842). Trial breath is done to
help determine patient status

I: The nurse will analyze and respond to ABG,

end tidal Co2 levels and pulse oximetry values
during the shift

R: End tidal Co2 monitoring is best used as an

aide to direct client observation and is used to
monitor a client’s ventilator status and
pulmonary blood flow (p. 842). Lab values are
critical to monitoring and trending a patients
status

I: The nurse will implement steps to prevent

VAP, including removal of subglottic secretions,
elevation of head of bed, and hand washing every

Clinical Course Pack – NUR 347L 33

 shift

R: The accumulation of contaminated

oropharyngeal secretions above the
endotracheal tube may contribute to the risk
of aspiration (p. 842). Steps to reduce VAP is
best care for the patient, these steps prevent
further decline

I: The nurse will provide routine oral care using

toothbrush or sponge and oral rinsing with an
antimicrobial agent if needed every 2 hours

R: Chlorhexidine reduces early ventilator

associate pneumonia in clines without
pneumonia at baseline. (p. 843). This is also an
order and helps prevent VAP

I: The nurse will reposition the client every 2

hours

R: Changing position frequently decreases the

incident of atelectasis, pooling of secretions
and resultant VAP (p. 843) Proper care for the
patients skin

I: Nurse will maintain proper cuff inflation for

endotracheal tube with minimal leak volume or
minima occlusion volume to decrease risk of
aspiration and reduce of VAP during the shift

R: To ensure adequate ventilation and

delivery of desired tidal volume (p. 920)

Clinical Course Pack – NUR 347L 34

 I: The nurse will auscultate breath sounds
periodically noting abnormal breath sounds every
2 hours

R: May indicate developing complications (p.

920). Important in trending patient status and
giving best care

I: The nurse will keep resuscitation bag at bedside

during the entire of stay

R: To allow for manual ventilation whenever

indicated (p. 920). In an emergency this is life
saving and the nurse should always be
prepared.

Clinical Form 5: Nursing Care Plan Diagnosis

NURSING DIAGNOSIS DESIRED OUTCOMES INTERVENTIONS WITH EVALUATION OF

WITH DESIRED OUTCOMES
RATIONALE WITH
SUPPORTING DATA
SUPPORTING

OBSERVATIONS

(REVISIONS PRN)

Clinical Course Pack – NUR 347L 35

Caregiver Role Strain
related to duration of
caregiving, unpredictability
of care situation and care
recipients health status as
evidenced by caregiver
fatigue, patient stating
concern about family
member, decisional conflict
and spiritual distress.
Clinical Course Pack – NUR 347L
LTO: The patient’s
caregiver will identify
resources available to help in
giving care or to support the
caregiver to give care before
patient is discharge home.
STO: The patients caregiver
will take part in self-care
activities to maintain own
physical and psychological/
emotional health during my
shift
STO: Caregiver will express
more realistic understanding
and expectations of the care
receiver
I: Nurse will monitor for signs of depression, -Outcome in progress.
anxiety, burden and deteriorating physical health During my shift family was
in the caregiver during the shift aware of changes that
would occur upon
R: The rate of depression in a family caregiver discharge. Communication
can be greater than that of the patient with with interdisciplinary team
chronic illness (p. 193) member facilitated.
I: The nurse will assess the caregivers emotional Discussion of home care
health at regular intervals during the shift needs and current plan of
care discussed. Facilitated
R: Research has confirmed the helpfulness of a meeting with case
number of evaluation tools for caregiver stress, management. Continue plan
including the Caregiver Reaction Assessment of care
(p. 193).
I: The nurse will identify potential caregiver
resources such as mastery, social support, -Outcome met during my
optimism and positive aspects of care during the shift. Caregiver was
shift delivered hospital meals of
her choosing. Caregiver
R: Research has shown that caregivers can took breaks to communicate
have simultaneous positive and negative with family and friends.
response to providing care (p. 194). Part of Caregiver took 2 hours to
care for the patient is care of the family go home for self-care. She
looked more put together
I: Arrange for intervals of respite care for the
and rested after going home
caregiver and encourage use during the shift
for a two hours. Continue
R: Respite care offers time away from the care plan of care
position and can help relieve distress
-Outcome met during my
36
 I: The nurse will help the caregiver find personal shift and in progress.
time to meet his or her needs, learn stress Caregiver understood
management techniques every 4 to 6 hours during realistically she must take
the shift care of herself first. She
agreed to go home for a bit
R: Due to amplified risk for deprived physical to shower and spend some
health as a result of providing care, caregivers time outside of the hospital.
must feel permitted to maintain self-care Expectations of care for
activates patient once discharged
I: The nurse will encourage the caregiver to talk needs to be discussed
about feelings, concerns, uncertainties and fears further and an
during the shift or PRN understanding of self-care
needs to be part of that plan.
R: Interventions to provide support for family Continue to monitor and
caregivers have shown improvement in progress
caregiver health (p. 194).

I: The nurse will involve the family in care

transition using the multidisciplinary team to
provide medical and social services for
instruction and planning before discharge of the
patient

R: Support group can improve depressive

symptoms and burden, particularly for female
care givers (p. 194). It is very important to
involve a family in a patients care

I: The nurse will help a caregiver problem solve

to meet the patient’s needs as needed during the
shift

Clinical Course Pack – NUR 347L 37

 R: Using a psycho-educational or problem-
solving intervention can decrease caregiver
feelings of strain (p. 195).

I: The nurse will encourage regular

communication with the patient and the health
care team during the shift and every time a new
health care team member is introduced

R: Caregivers’ preferential communication

method and communication needs should be
addressed at regular intervals to improve their
sense of mastery over the care situation (p.
194) Sometimes rounding can be
overwhelming and a nurse can bridge the gap

I: The nurse will acknowledge difficulty of the

situation for the caregiver/family

R: Research shows that the two greatest

predictors of caregiver strain are poor health
and the feeling that there is no choice but to
take on additional responsibilities (p. 716).

I: The nurse will encourage attention to own need

of the care giver multiple times a shift

R: Supports and enhances caregivers general

well-being and coping ability (p. 717).

I: The nurse will educate the care giver on signs

of burnout during the shift

R: Recognition of developing problems allow

Clinical Course Pack – NUR 347L 38

 for timely intervention (p. 717). Discharge
planning and plan of care begin at admission

Clinical Course Pack – NUR 347L 39

Student Name:
Clinical Form 5: Nursing Care Plan: Diagnosis
NURSING DIAGNOSIS
WITH SUPPORTING
DATA
Ineffective Airway
Clearance related to
presence of artificial
airway as evidenced by
dyspnea, alteration in
respiratory rate and pattern
and diminished breath
sounds.
Clinical Course Pack – NUR 347L
DESIRED OUTCOMES
LTO: The patient will
maintain adequate, patent
airway on their own by
discharge from the ICU
STO: The patient will
mobilize secretions with
assistance by the nurse by
suctioning and good oral
hygiene every two hours
STO: The patient will utilize
hospital personal to prevent
the passage of fluid and solid
particles into the lungs
during my shift
EVALUATION OF
DESIRED
INTERVENTIONS WITH RATIONALE OUTCOMES WITH
I: The nurse will identify risk for excessive or
SUPPORTING
abnormal mucus production during her shift
OBSERVATIONS
R: Excessive and or sticky mucus can completely
obstruct or make it difficult to maintain effective (REVISIONS PRN)
airways especially if pt is mechanically ventilated
(p. 50) Keeping airway clear promotes airway
clearance. -Outcome not met on my
I: The nurse will identify risks due to patient being shift, in progress. Patient
had positive trending
immobile and sedated during her shift
ABG
R: Body movement benefits mobilizing
-Outcome met.
secretions
Suctioning PRN with
I: The nurse will assess level of consciousness and good return and normal
ability to protect own airway every hour secretions that did not
present any blood or
R: This information is important for identifying other foreign substance.
probable for airway problems, providing baseline Oral care performed
level of care needed and influencing choice of every 2 hours on
interventions. (p. 50) schedule to patient
40
 I: The nurse will evaluate respiratory rat/depth and comfort and to prevent
breath sounds every hour or PRN VAP. Continue plan of
care.
R: Tachypnea is usually present to some degree
and may be pronounced during respiratory
stress, respiratory by be shallow, wheezing
indicates airway obstructions (p. 130) VS are a
prime resource for changing
(improving/declining) status

Clinical Course Pack – NUR 347L 41

 I: The nurse will evaluate amount and type of -Outcome met. Utilized
secretions being produced every hour or PRN respiratory therapist who
maintained adequate
R: Excessive and or sticky mucus can completely ventilator settings.
obstruct or make it difficult to maintain effective Administered medication
airways especially if pt is mechanically ventilated as ordered in a timely
(p. 50) Documentation and trending aids in manner to maintain
continuous care of the patient sedation. Breath sounds
I: The nurse will suction when indicated, using remained the same with
correct sized catheter and suction timing during her no abnormal findings
shift and PRN beyond baseline
assessment of R lower
R: To clear airway when secretions are blocking crackles and L lower
airways, client is unable to clear airway by diminished breath
coughing and is ventilated. This will be done if sounds. Continue plan of
client is showing desaturation of oxygen by care
oximetry (p. 51) Proper techniques for clearing
the airway are top priority

I: The nurse will change patient position as needed

every 2 hours

R: Changing position frequently decreases the

incidence of atelectasis, pooling of secretions and
resultant pneumonia (p. 131). Nursing protocol
and keeps patient from gaining skin
complications

I: The nurse will exercise diligence in providing oral

hygiene removing substance and keeping oral
mucosa hydrated every 2 hours or PRN

Clinical Course Pack – NUR 347L 42

 R: Airway can be obstructed by substances such
as blood or thickened secretions. These can be
managed by strict attention to good oral hygiene
especially in the patient unable to provide for
themselves. (p. 51). Oral care reduces VAP

I: The nurse will mobilize client as soon as possible

R: Reduces risk or effects of atelectasis,

enhancing lung expansion and drainage of
different lung segments (p. 51). Movement
promotes healing and decreases ICU time

I: The nurse will administer analgesics as indicated

during her shift

R: Analgesics may be needed to improve smooth

respiratory musculature, reduce airway edema
and mobilize secretion (p. 51). This will keep the
patient rested for healing

I: The nurse will assist with respiratory devices and

treatment or delegate to the appropriate staff during
her shift

R: Various therapies/modalities may be required

to maintain adequate airway and improve
respiratory function and gas exchange depending
on the cause for airway impairment (p. 51).
Delegation to a staff member who is more
knowledgeable gives patient best care

I: The nurse will monitor, document and report vital

Clinical Course Pack – NUR 347L 43

 signs every hour or PRN

R: Oxygen administration has been shown to

correct hypoxia (p. 130).

I: The nurse will explain, hyperoxygenate, suction

for less than 15 seconds, use a closed suction
system, document when performing suctioning
every time suctioning is performed

R: Studies have demonstrated that

hyperoxygenation may help prevent desaturation
and a drop in partial pressure of procedure
taking 15 seconds is safest. Closed line suctioning
has minimal effects on heart rate, respiratory
rate, tidal volume, and oxygen saturation (p. 131)
Proper suctioning techniques is always important
and benefits the patients outcome

Ackley, B., & Ladwig, G. (2011). Nursing Diagnosis Handbook. (9th ed.). St. Louis, Missouri. Copyright Mosby Elsevier.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nursing diagnosis manual: Planning, individualizing, and documenting client
care. Philadelphia: F.A. Davis.

Clinical Course Pack – NUR 347L 44

Student Name:

Clinical Form 6: Discharge Planning Form

DISCHARGE PLAN OF CARE:

1. Where will your patient go upon discharge (d/c) and what arrangements have
been made?
Currently my patient has no anticipated discharge date. Her family has been part of her care team
for many years and she lives with a daughter. The plan will be for her to go back with the
daughter based on a positive outcome of her hospital stay. Currently no new arrangements need
to be implicated. Further follow up appointments and strict regulation of HTN and DM has also
been addressed with the family.

2. If going home, is home layout appropriate for pt’s needs? Yes No

The family has been educated, living arrangements and help has been arranged. Patient uses a
wheelchair and her living situation is set up for this type of care. Based on a positive outcome of
the patients hospital stay she will resume living at the daughters house that is set up for
wheelchair access and patients room and bathroom are also set up according to patient’s needs.

1. What support is needed (include financial, home health nurse, home 02, PT, meals on
wheels)?

Patient lives with a daughter who is a Respiratory Therapist and care of patient is shared with the
other daughter who is a PA. They have cared for their mother for many years in the home. The
home is set up currently for the patient and her wheelchair. Based on a positive outcome of the
patients hospital stay the patient will resume living with the daughter and the family will
continue in home care.

4. What d/c teaching does pt and/or family need (include follow-up care, activity level,
new meds, dressing changes, accucheck, diabetic care, special diet, etc.)?
The family has been educated about the needs of the patient. Any new medications prescribed at
discharge will be discussed with the daughters. There will be follow up appointments for the
patient but the family has always juggled her medical schedule together and understands the
importance of following up. Family has been educated on sign and symptoms and lifestyle
changes that need to be made. Daughter states incompliance by the patient regarding her DM

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regardless of patient teaching. Daughter’s state trying to care for their mother the best they can
even with her incompliance.

5. If pt is going to a medical facility, what information is needed on the transfer form

(include level of care and specific treatments required)?
Patient will be transferred in-house to a lower acuity floor before full discharge can be arranged.
The hospital is well equipped to transfer lower acuity patients for ICU to med/surg.

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 Clinical Form 7: Client Teaching Form

Client’s readiness to learn:

Unable to establish at this time, Family bedside extreme readiness to learn

Client’s preferred method of learning:

Unable to establish at this time, Family well educated and direct clear communication
established. Verbal method of learning with written method when appropriate.

TOPIC/CONTENT Assessment of Content taught and Evaluation of

client/family ‘method’ used* learning
knowledge level

Family very Reminded family All family did wash

Importance of contact
precautions for a
patient with C-diff
knowledgeable about and friend of the their hands
health care and importance of properly
providing care due hand washing;
to backgrounds in Verbal teaching
healthcare. Followed
exact precautions

Medication Family very Verbally Family understood

administration knowledgeable about communicated medications given.
precautions and follow health care and every drug I They knew why she
through providing administered. was receiving them.
Explained when They were receptive
we made changes to the changes in
to sedation level sedation. During
trial breathing
daughter stayed
bedside to help
calm her mother.
She understood and
I reviewed reason
for trial breathing.

Self-care for the Daughter Verbal teaching Daughter finally

knowledgeable about and active took a break from

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caretaker how important self- listening to the hospital and
care was but was portray the went home for two
reluctant to accept it importance of self- hours. Further
for herself. care to the reminders and
daughter. teaching should be
done. Possible
support group or
additional care
services will need to
be provided for the
family.

Family very Verbal teaching Daughter

Reason for ventilation
and sedation
knowledgeable about from nurse and understood reason
health care and resp therapist. for sedation while
providing care Daughter was very ventilation. Had no
understanding of questions.
all the terms and
reason for
ventilation

Family very Verbal teaching When a patient is

Care of patient while
ventilated and sedated
knowledgeable about and sedated this does
health care and communication not mean they may
providing care. were performed. not hear or
Knowledgeable of Patient sedated so remember their
tubing and alarms every action taken care. It is important
was to talk and treat the
communicated patient as if they
even though are awake.
patient was did
not respond.

*Attach a separate sheet that indicates all the topics that should be included in a
comprehensive teaching plan.

When patient is weaned from sedation there will be multiple teachings that will need to be
performed. When the patient is downgraded all the way till discharge there will need to be verbal
and written teaching in the patients’ plan of care.

 Daily weights

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  Diet changes
 Importance of follow up appointments
 Possible hospice care
 Skin care
 Signs and symptoms of hypoglycemia and hyperglycemia
 Signs and symptoms of uncontrolled hypertension
 Signs and symptoms of exacerbation of HF
 Caretaker burnout

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