Nursing Clinical Packet

Patient Assessment and Care Plan

Instructions to student:

1) Bring one copy of this packet with you to clinical each week.

2) Your instructor will inform you of the number of packets and the dates each packet is due. They may have you complete only portions of or all of the packet.

3) Read the rubric! Each packet is Pass/Fail. You must meet the requirements listed to receive a Pass. Your instructor may ask you to resubmit packets that are incomplete or incorrect.

4) If your instructor asks you to submit the packet electronically, then please record your answers in bold or in a colored or lower case font. This helps us identify your answers more quickly.

 PATIENT ASSESSMENT FORM

STUDENT NAME:

DATE:

CLIENT INITIALS:	ROOM #	DOB:	AGE	GENDER:	ADMISSION DATE:
CODE STATUS:	ALLERGIES:	MARITAL STATUS:	OCCUPATION (FORMER):
MEDICAL DX:	CHIEF COMPLAINT:
PAST HISTORY (SURGERY/PROCEDURES) WITH DATES
	ORDERS	RATIONALE (Why is this ordered for this client???)
EXAMPLE: DIET	2 g Sodium diet with nectar thick liquids only	Sodium is restricted due to edema in the bilateral lower extremities and nectar thick liquids due to dysphagia from a past stroke.
DIET
ACTIVITY
I/O
VS
BGM
FOLEY
NG
PEG/PEJ TUBE
WOUND CARE
RESPIRATORY TREATMENT
TRACHEOSTOMY
SUCTIONING
CHEST TUBE
SPECIAL EQUIPMENT
LAB ORDERS
OTHER
REHAB SERVICES	ACTIVITY OR TREATMENT PLAN & SCHEDULE	RATIONALE
PHYSICAL THERAPY
SPEECH THERAPY
OCCUPATIONAL THERAPY

/ 5 pts

IVs

IV FLUID AND RATE:	SITE LOCATION AND CONDITION:
LAST DRESSING CHANGE:	LAST TUBING CHANGE:
GAUGE:	REASON FOR IV ACCESS:

DIAGNOSTIC TESTS:	DATE	RESULTS	REASON FOR TESTING AND IMPLICATIONS FOR NURSING CARE

LAB TEST	DATE	RESULTS	NORMS REFERENCE RANGES	IMPLICATIONS FOR NURSING CARE (WHAT S&S I SHOULD BE AWARE OF AND WHAT YOU CAN DO TO HELP IMPROVE AN ABNORMAL RESULT?)

GROWTH and DEVELOPMENT: (see pages 378-379 Taylor, Lillis and White) or (Erikson’s Stages of Development)

CLIENT’S DEVELOPMENTAL STAGE ACCORDING TO HAVIGHUSRT	TASKS OF THIS STAGE:
ASSESSMENT OF CLIENT’S SUCESSFUL ACHIEVEMENT OF TASKS

/ 5 pts

MEDICATIONS

If your client has more than 12 medications, select the 12 medications that are most important, most frequently given or those that pertain to the client’s most significant medical problems. See the example below.

Brand Name and Generic Name	Normal Dosage Ranges	Contraindications
Coreg (carvedilol)	3.125 mg – 50 mg BID	Asthma, heart block
Pharmacotherapeutic Class	Dosage, Route & Frequency	Adverse Reactions
β-adrenergic blocker	6.25 mg p.o. BID	Bradycardia, CHF, thrombocytopenia, hyperglycemia, bronchospasm
Why this Patient Receives this Med	Effects of the Med on the Client	Nursing Considerations and Teaching
He has a history of hypertension but has been taking Coreg for 2 years to control his hypertension	BP’s for past 3 days have been 128/78, 132/72, 138/80How is this medication impacting your client??B/P readings, lab results, pain management, etc……..	Do not discontinue abruptly or before surgeryCaution with Upper airway dysfunctionRise slowly to minimize orthostatic hypotension, check B/P and heart rate prior to administrationTake before meals

#1 Brand Name and Generic Name	Normal Dosage Ranges	Contraindications
Pharmacotherapeutic Class	Dosage, Route & Frequency	Adverse Reactions
Why this Patient Receives this Med	Effects of the Med on the Client	Nursing Considerations and Teaching

#2 Brand Name and Generic Name	Normal Dosage Ranges	Contraindications
#3 Pharmacotherapeutic Class	Dosage, Route and Frequency	Adverse Reactions
Why this Patient Receives this Med	Effects of the Med on the Client	Nursing Considerations and Teaching

#4 Brand Name and Generic Name	Normal Dosage Ranges	Contraindications
Pharmacotherapeutic Class	Dosage, Route and Frequency	Adverse Reactions
Why this Patient Receives this Med	Effects of the Med on the Client	Nursing Considerations and Teaching

#5 Brand Name and Generic Name	Normal Dosage Ranges	Contraindications
Pharmacotherapeutic Class	Dosage, Route and Frequency	Adverse Reactions
Why this Patient Receives this Med	Effects of the Med on the Client	Nursing Considerations and Teaching

# 6 Brand Name and Generic Name	Normal Dosage Ranges	Contraindications
Pharmacotherapeutic Class	Dosage, Route and Frequency	Adverse Reactions
Why this Patient Receives this Med	Effects of the Med on the Client	Nursing Considerations and Teaching

#7 Brand Name and Generic Name	Normal Dosage Ranges	Contraindications
Pharmacotherapeutic Class	Dosage, Route and Frequency	Adverse Reactions
Why this Patient Receives this Med	Effects of the Med on the Client	Nursing Considerations and Teaching

#8 Brand Name and Generic Name	Normal Dosage Ranges	Contraindications
Pharmacotherapeutic Class	Dosage, Route and Frequency	Adverse Reactions
Why this Patient Receives this Med	Effects of the Med on the Client	Nursing Considerations and Teaching

#9 Brand Name and Generic Name	Normal Dosage Ranges	Contraindications
Pharmacotherapeutic Class	Dosage, Route and Frequency	Adverse Reactions
Why this Patient Receives this Med	Effects of the Med on the Client	Nursing Considerations and Teaching

#10 Brand Name and Generic Name	Normal Dosage Ranges	Contraindications
Pharmacotherapeutic Class	Dosage, Route and Frequency	Adverse Reactions
Why this Patient Receives this Med	Effects of the Med on the Client	Nursing Considerations and Teaching

#11 Brand Name and Generic Name	Normal Dosage Ranges	Contraindications
Pharmacotherapeutic Class	Dosage, Route and Frequency	Adverse Reactions
Why this Patient Receives this Med	Effects of the Med on the Client	Nursing Considerations and Teaching

#12 Brand Name and Generic Name	Normal Dosage Ranges	Contraindications
Pharmacotherapeutic Class	Dosage, Route and Frequency	Adverse Reactions
Why this Patient Receives this Med	Effects of the Med on the Client	Nursing Considerations and Teaching

/ 20 pts

NURSES NOTES FOR CLINICAL

For this clinical, we are having you write out your assessment findings in the form of a narrative nurse’s note. We have provided some samples of assessments. We have also provided a worksheet that you may use to take into a patient’s room to take notes during your assessment. Record your vital signs and type your physical assessment findings. This form will expand to fit your typing. A sample of charting for a long term care resident follows below.

TEMP:

APICAL HR:

RESP:

BP:

HT:

WT:

DATE / TIME

(TYPE HERE)

Sample Narrative Note — Head to Toe format

Temp: 98.6

Apical HR: 72

Resp: 16

BP 128/62

Ht: 5’10”

Wt: 145

12/22/2010 1400

Resident in semi-fowlers position in bed. Pressure reduction mattress in place. Alert and oriented x 3. Appropriate mood and affect. Well groomed. Recent and remote memory intact. Facial symmetry noted. Pupils are equal, reactive to light and accommodation. Oral mucosa moist, pink. Frequent oral care rendered with sponge toothette and toothbrush. Dentition intact. Hearing intact. Oropharynx clear without erythema or exudate. No chewing or swallowing difficulties. 75% of general diet taken at breakfast. Skin pink, warm, dry, free of lesions with elastic turgor. Hair and nails unremarkable. Carotid and radial pulses present and equal. Motor and sensory functions grossly intact. No weakness or paralysis. Upper extremities equal strength bilaterally, full ROM w/ capillary refill < 3 sec. Fine resting tremor in the left hand” No involuntary movement or abnormal posture. Lungs clear bilaterally to auscultation. Tracheostomy dressing clean, dry, and intact. Connected to ventilator with settings: TV-550, Fio2-40%, Rate 10, and PEEP-5cm. Sao2-92%. Suctioned for moderate amount of white, thin secretion. Apical pulse regular (rate) and rhythm. Double lumen picc line note to left antecubital space. Tegaderm dressing is clean, dry, and intact. Last dressing change on 11/28/16. Chlorhexadine caps intact to all lumens. Bowel sounds active x 4. Abdomen soft, non-distended, non-tender. Last bowel movement this morning, passed a large, soft- formed brown stool and a moderate amount of clear yellow urine. Bilateral lower extremities, no tenderness, swelling or joint deformities noted. Denies numbness or tingling to extremities. Toe nails thick and yellowed w/ capillary refill < 3 sec. No peripheral edema noted, pedal pulses palpable and equal bilaterally.

PHYSICAL ASSESSMENT WORKSHEET (Use this sheet for jotting down your assessment findings.)

ROUTINE FINDINGS	PATIENT VARIATIONS/ABNORMALS
COGNITION/NEUROLOGICAL (SAMPLE) Alert and oriented x3, recent and remote memory intact. Denies any numbness or tingling to extremities”	(SAMPLE) “Fine resting tremor of left hand
SKIN
SENSORY	Wound measurements and complete description if available at the very least Document dressing including the type of dressing and description of condition!
BREASTS –	DEFERRED.
RESPIRATORY –	(Include ventilator settings as indicated in narrative note)
CARDIOVASCULAR	Include any vascular access device, IV lines, AV fistulas, perma -cath lines, etc.
ABDOMEN –.	Include any enteral feedings here and routeBOWEL CONTINENCE? LAST BM? BOWEL PLAN?
MUSCULOSKELETAL –
GENITOURINARY –	URINARY CONTINENCE? TOILETING PLAN?
PELVIC –	DEFERRED.
RECTAL –	DEFERRED.

/ 10 pts

1

NURSING CARE PLAN Begin your NCP by listing ALL your clients individual problems (at least 10) and then identify an appropriate nursing diagnosis that you can think of that would apply to your client. Determine which 3 problems/nursing diagnoses are of greatest priority and then add a #1, #2, and #3 to indicate which of the two have highest priority. Risks would not be priority 1, 2, or 3!!!!!

Expectation is to have at least 10 nursing diagnosis listed!

#	List the Client problem	An appropriate Nursing Diagnosis stem(REFER TO YOUR NURSING DIAGNOSIS LIST)	Related to part of the statement (This is individual to your client)	As evidenced by part of the statement (This is individual to your client)REMEMEBR THIS IS NOT USED IN A “Risk For” diagnosis
1	SAMPLE: Reports severe pain in the right hip.	“Acute Pain”	“related to” fractured right hip	“as evidenced by” verbal report of pain rated at an 8 on a scale of 0 –to 10.
2	SAMPLE: Complete bed rest	“Risk for Impaired skin integrity”	“related to “ immobility	NONE it is a “Risk for” diagnosis so there is no evidence statement

From the list above your faculty member will give you direction regarding how many and which diagnoses they want you to develop for either a Nursing Care Plan and/or a Concept Map.

SAMPLE NCP

NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED BY STATEMENT: Acute Pain related to right hip fracture as evidenced by a verbal report of pain rated 8 on a scale of 0 -10.

ASSESSMENT(Data that directly pertains to the above nursing diagnosis)	OUTCOME STATEMENT(Patient centered, realistic, specific, measurable, target time)	INTERVENTIONS(Individualized, specific, frequency)Minimum of 4-5 interventions per plan	SCIENTIFIC RATIONALE(Supporting statement from text or other source, cite source)	EVALUATION OF OUTCOME(Met, partially met, unmet, unknown by target time)
SUBJECTIVE DATA: “My right hip hurts me so much every time I move. I am so afraid to start physical therapy”	SHORT TERM: Client will report pain level rated at a 3 or lower 30 minutes after pain medication taken	1. Educate the client on the importance of pain relief to enhance her rehabilitation efforts and include education on various types of methods to relieve pain.2. Encourage client to express any questions or concerns she may have regarding pain management methods to alleviate anxiety and fears.3. Educate the client on her responsibility to honestly report pain when it occurs as well as reporting if the current pain management is effective or ineffective for providing her pain relief4. Provide for alternative/complementary measures of pain relief, such as, reduce lighting and noise, soothing music, pet therapy, massage, and hot/cold packs according to client preferences.	1. “There are many ways to manage pain. In addition to pharmacologic and non-pharmacologic measures, simple nursing interventions can alter patients’ pain experience and speed their recovery.” Taylor, Lillis and White pg. 1168.2. “Common fears include a loss of control and embarrassment by being unable to deal with pain maturely… The patient may view the need of for medication as a sign of weakness or may fear addiction or loss of effectiveness at a later date.” Taylor, Lillis and White pg. 1169.3. “As a patient advocate, ensure that a strong emphasis on the need for aggressive, individualized strategies that can minimize or eliminate acute pain and improve patient outcomes. Preventing pain is easier then treating it once after it occurs.” Taylor, Lillis and White pg. 1178.4. Alternative/complementary measures will provide an added benefit of distraction from pain experience and augment analgesic effect. Cold/hot therapy can provide constriction and or dilation which will reduce pain inflammation in each specific circumstance Daniels. Pg 378	Short Term Goal: Met; pain was rated at a 2 on a scale of 0 to 10 after administration of Vicodin.Long Term Goal. In progress
OBJECTIVE DATA:Alert and oriented 70 year old widowed female. Lives in an apartment independently. 2 daughter live nearby and visit often.History of a fall while out shopping 1 ½ weeks ago. Right hip surgically repaired 7 days ago. Surgical dressing to right hip is clean, dry and intact. Circulation, motion and sensation intact to right lower extremity.Afebrile; BP 124/80; R-18 AP 84 and regular. 5 foot 7 inches weighs 142 pounds. No hearing deficits; wears eye glassesMedical history positive for osteoarthritis and osteoporosisNon weight bearing to right leg and to use a walker for ambulationTo start physical therapy for gait and strength training BID times 7 days and occupational therapy to develop upper body strength once daily times 7 daysReports pain level is at 8 on a scale of 0 to 10.Has Vicodin 5mg/325 mg po 2 tabs every 4 hours prn for severe painIbuprofen 400 mg every 6 hours prn for moderate pain.	LONG TERM: Client will report pain level of 2 or less using ibuprofen with alternative pain control methods by discharge.

Short term outcome: An outcome that can be accomplished by the end of the student clinical day.

Interventions: Each nursing intervention must come from a reliable nursing reference or source. Please note: do not use nursing care planning book exclusively. Not more than one intervention can come from a source outside your textbooks.

Rationales: Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org)

NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED BY STATEMENT:

ASSESSMENT(Data that directly pertains to the above nursing diagnosis)	OUTCOME STATEMENT(Patient centered, realistic, specific, measurable, target time)	INTERVENTIONS(Individualized, specific, frequency)	SCIENTIFIC RATIONALE(Supporting statement from text or other source, cite source)	EVALUATION OF OUTCOME(Met, partially met, unmet, unknown by target time)
SUBJECTIVE DATA:	SHORT TERM:
OBJECTIVE DATA:	LONG TERM:

Short term outcome: An outcome that can be accomplished by the end of the student clinical day.

Interventions: Each nursing intervention must come from a reliable nursing reference or source. Please note: do not use nursing care planning book exclusively. Not more than one intervention can come from a source outside your textbooks.

Rationales: Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org)

/30

NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED BY STATEMENT:

ASSESSMENT(Data that directly pertains to the above nursing diagnosis)	OUTCOME STATEMENT(Patient centered, realistic, specific, measurable, target time)	INTERVENTIONS(Individualized, specific, frequency)	SCIENTIFIC RATIONALE(Supporting statement from text or other source, cite source)	EVALUATION OF OUTCOME(Met, partially met, unmet, unknown by target time)
SUBJECTIVE DATA:	SHORT TERM:
OBJECTIVE DATA:	LONG TERM:

Short term outcome: An outcome that can be accomplished by the end of the student clinical day.

Interventions: Each nursing intervention must come from a reliable nursing reference or source. . Please note: do not use nursing care planning book exclusively. Not more than one intervention can come from a source outside your textbooks.

Rationales: Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org)

/30

NANDA DIAGNOSIS STATEMENT /RELATED TO STATEMENT/AS EVIDENCED BY STATEMENT:

ASSESSMENT(Data that directly pertains to the above nursing diagnosis)	OUTCOME STATEMENT(Patient centered, realistic, specific, measurable, target time)	INTERVENTIONS(Individualized, specific, frequency)	SCIENTIFIC RATIONALE(Supporting statement from text or other source, cite source)	EVALUATION OF OUTCOME(Met, partially met, unmet, unknown by target time)
SUBJECTIVE DATA:	SHORT TERM:
OBJECTIVE DATA:	LONG TERM:

Short term outcome: An outcome that can be accomplished by the end of the student clinical day.

Interventions: Each nursing intervention must come from a reliable nursing reference or source. . Please note: do not use nursing care planning book exclusively. Not more than one intervention can come from a source outside your textbooks.

Rationales: Cite a reliable source for each intervention (name of text, author, page number, internet site and date retrieved (reliable sites: .gov or .edu. or .org)

/30

3

Key Problem: Impaired urinary elimination

Data:

Intake=3800 Output=3200

Polyuria

3+ glucose in urine

AEB: Polydipsia and polyuria

Outcomes:

Pt. will have urine output of 1000 – 2000 ml/24 hours.

Interventions:

Monitor I & O q shift.

Monitor BGM a.c. and h.s.

Monitor kidney function tests

Administer antihyperglycemics as ordered.

Key Problem: Knowledge deficit

Data: Pt verbalizes confusion about diagnosis, new meds, diet, exercise routine

AEB: Verbal statements and questions.

Outcomes:

Pt will verbalize understanding of ADA diet and administer insulin using appropriate technique by discharge.

Interventions:

Assess level of knowledge regarding diabetes/ treatment and client’s preferred learning style.

Provide information q shift according to teaching plan recorded in EMR and document pt’s response.

Reassess level of knowledge daily.

Provide written information.

Provide educational resources available in the community.

4

Medical Problems (Pathophysiology)/Surgical Procedures:

Newly diagnosed diabetic

Key Assessments:

S/S of hyper and hypoglycemia, good intake, I/O, glucose level, vitals

Tests: FBS, hemoglobin A1C

“I don’t know how this fits”

Recent widow

Kids live out of state

? support system

1

Key Problem: Acute anxiety

Data: Restless, verbally states she is anxious.

AEB: Pt states “I don’t know what I will do with diabetes, this is too much.”

Outcomes: Pt. will verbalize under-standing of resources available by discharge.

Interventions:

Provide pt. with an opportunity each shift to verbalize anxiety by asking open ended questions.

Demonstrate progressive relaxation exercises and have pt. return demonstrate.

Provide pt. with a list of community resources for newly diagnosed diabetics.

Identify client’s perception of anxiety

Utilize empathy.

2

Past Medical History: Hypertension x 20 years; appendectomy at age 9.

Risk Factors: Mother had Type 2 diabetes; hypertension; Native American descent; sedentary lifestyle; 290 pounds, age 52

Key Problem:

Imbalanced nutrition, more than

Data:

BMI: 35.0–39.9; Ht: 5”9; Wt: 290 lbs

AEB: Anthropometric measurements.

Outcomes: Client will verbalize a realistic weight loss goal and three strategies to reach it prior to discharge.

Interventions:

Assess client’s knowledge of nutrition and its relationship to diabetes.

Arrange for dietary consultation.

Reinforce teaching by dietician.

Encourage physical activity as a weight loss strategy.

Provide pt with community resources that can assist her with weight loss goal.

“I DON’T KNOW HOW THIS FITS”

PAST MEDICAL HISTORY

RISK FACTORS

MEDICAL PROBLEMS (PATHOPHYSIOLOGY)/SURGICAL PROCEDURES:

KEY ASSESSMENTS:

Key Assessments:

Tests:

KEY PROBLEM:

DATA:

AEB:

OUTCOMES:

INTERVENTIONS:

KEY PROBLEM:

DATA:

AEB:

OUTCOMES:

INTERVENTIONS:

RUBRIC for Grading Packets

/60pts

KEY PROBLEM:

DATA:

AEB:

OUTCOMES:

INTERVENTIONS:

KEY PROBLEM:

DATA:

AEB:

OUTCOMES:

INTERVENTIONS:

Student Name:

Clinical Date:

Site:

Section	Grading Criteria	Satisfactory Or Unsatisfactory	Comments, Kudos,Things to Improve for Next Time
10 pointsPatient Demographics,Diagnoses, Surgeries, Orders, Rehab, IV, Imaging and Lab	Page 1 fully and correctly completed 5 ptsPage 2 fully and correctly completed 5 pts	_/5____/5___
20 pointsMedications	Medication Trade Name 2 ptsMedication Generic Name 2 ptsPharmacological Classification 2 ptsNormal Dosage Range 2 ptsDose ordered 2 ptsRoute and Frequency 2 ptsContraindications 2 ptsAdverse Effects/Reactions 2 ptsNursing Considerations & Teaching 2 pts(Legible or typed) 2 pts	/ 2/ 2/ 2/ 2/ 2/ 2/ 2/ 2/ 2/ 2_/20__
10 pointsNarrative NotesHead-to-Toe Assessment	Narrative note is in Head to Toe orderHead-to-toe assessment documented Abnormal results noted 10 pts	___/10_
60 points (either a Concept Map or a Patient Care Plan)Concept Map	Correct Medical Diagnosis 15 ptsPathophysiology 15 ptsKey Assessments 15 ptsAt least 3 problems identified 15 pts	____/60OR
60 points (either a Concept Map or a Patient Care Plan)Patient Care Plan	3 nursing diagnoses Related to” “As evidenced by” 18 pts2 Outcomes specific, measurable, timed 8 pts4-5 Interventions are logical, appropriate 15 pts4-5 Scientific Rationales supporting each intervention 15 pts 2Evaluations 4 pts	____/60

 

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In a 1,000-1,250 word paper, provide an analysis that includes the following:

1. Brief summary description of the type of risk management plan you selected (new employee, specific audience, community-focused, etc.) and your rationale for selecting that example.
2. Description of the recommended administrative steps and processes in a typical health care organization risk management program contrasted with the administrative steps and processes you can identify in your selected example plan. (Note: Select an example plan with sufficient data to be able to complete the assignment successfully.)
3. Analyze the key agencies and organizations that regulate the administration of safe health care and the roles each play in the risk management oversight process.
4. Evaluation of the selected exemplar risk management plan regarding compliance with the American Society of Healthcare Risk Management (ASHRM) standards relevant to privacy, health care worker safety, and patient safety.
5. Proposed recommendations or changes you would make to your selected risk management program example to enhance, improve, or to secure compliance standards.

In addition to your textbook, you are required to support your analysis with a minimum of three peer-reviewed references.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. Please refer to the directions in the Student Success Center.

• Posted: 2 Months Ago
• Due: 20/05/2019
• Budget: $15

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Your written assignment for this module should be a 1-2 page paper (not including title page and reference page) that describes the following:

• Describe what a fluid and electrolyte imbalance is and how this is important to the function of the body?
• Pick a fluid or electrolyte imbalance and describe how the patient would present, in addition to the treatment (nursing and expected medical)?

You should include a minimum of 3 scholarly references. Include a title page, in-text citations, and a reference page in APA format.

Module 08 – Fluid Imbalances

Scoring Rubric:

Criteria

Points

Describe what a fluid and electrolyte imbalance and how this is important to the function of the body?

3

Pick a fluid or electrolyte imbalance and describe how the patient would present, in addition to the treatment (nursing and expected medical)?

5

Grammar, APA and Organization

2

Total

10

Module 08 – Fluid ImbalancesScoring

 Rubric:

 

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Purdue University Northwest

College of Nursing

Online RNBSN Program

INCLUSIVE PATIENT CASE STUDY

DIRECTIONS: Please answer all of the questions within the case study with comprehensive answers. You need to include at minimum two references: one can be your textbook and the other is your choice whether it be an article or another textbook. You must include in text citations as well as a reference list. Both should be in APA format.

Chief Complaint: Hyperglycemia

History of Present Illness: This is a 66 year old female that had labs drawn after a routine follow up visit with her primary care provider today. She received a call from the nurse practitioner telling her to go directly to the hospital for a glucose of 520mg/dl.

Past Medical History: Diabetes Mellitus Type II diagnosed at age 45. Emphysema diagnosed at age 55, Hypertension diagnosed at age 46, Hyperlipidemia diagnosed age 65.

Family History: +Hypertension- mother and father; +Lung cancer- mother; +diabetes- mother / sister

Social History: Tobacco dependence 1 pack per day for the last 46 years. Last cigarette this morning at 9am. Denies alcohol use. Denies illicit drug use.

Allergies: Penicillin

Medications: Glucophage 500mg po bid; Lisinopril 10mg po daily; Hydrochlorothiazide 50mg po daily; Aspirin 325mg po daily; Albuterol inhaler 2 puffs qid prn; Combivent 2 puffs qid; Advair 1 inhalation bid;

Review of Systems:

Constitutional Symptoms: +Weight loss 5 pounds in in the last month; +obese, +fatigue, +poor appetite Integumentary: +Color changes in lower extremities.

HEENT: Eyes: +Vision changes within the last week with +blurriness, +wears glasses; Ears: No hearing changes. Nose: Denies any problems. Throat: Denies sore throat or dysphagia.

Cardiovascular: +occasional chest pain with exertion, +hypertension well controlled – compliant with medications, swelling lower extremities for the last month; +varicose veins

Respiratory: +Dyspnea, +sputum, +wheezing, Emphysema – uses as needed albuterol inhaler once a day, and is compliant with Combivent and Advair, continues to smoke 1 pack per day of cigarettes.

Musculoskeletal: Denies joint pain, swelling, arthritis.

Gastrointestinal: +poor appetite; +nausea, +heartburn; +occasional abdominal pain lower quadrants.

Genitourinary: +polyuria, +polydipsia, denies polyphagia, + frequency, Denies dysuria, hematuria, burning, urgency

Neurological: Denies memory loss, tremors, numbness

Endocrine: +Diabetes compliant and well controlled – patient states her am fasting accucheck is 100-120mg/dl, +excessive thirst over the last 2 days.

Psychiatric: Denies Depression, anxiety, substance abuse.

Physical Exam

Vital Signs: T: 98.2; HR: 84; R: 24; B/P: 148/89; O2 sat: 90% on room air; Ht: 5’6’; Wt: 278; Waist circ: 48

Constitutional: Alert, Appears older than stated age.

Integumentary: Pink, warm, dry, and intact. Bilateral lower extremities with stasis dermatitis, +clubbing.

HEENT: Normocephalic, PERRLA, moist mucus membranes, neck supple, no thyromegaly. Cardiovascular: Reg rate /rhythm, no murmur/rub/gallop, S1/S2, edema 2+ pitting B/L lower extremities.

Respiratory: Tachypnea, slightly labored with expiratory wheezes.

Musculoskeletal: Normal and equal motor/strength/ROM.

Gastrointestinal: Abdomen soft, obese, nontender, nondistended, obese with active bowel sounds.

Genitourinary: Urine is clear, pale yellow.

Neurological: Awake, alert, oriented x 3. No tics. Hematologic/Lymphatic: Lymphadenopathy

Psychiatric: Calm, cooperative

Labs and Diagnostics: Table 14.2 Laboratory Blood Test Results

URNALYSIS:

Appearance: Pale yellow / clear (-) Nitrate (-) Bilirubin (+) Protein (-) Microalbuminuria

pH 5.8 Specific gravity 1.015 (+) Ketones (+)Glucose (-) Microscopy

CBC/CMP/LIPID PANEL

Na 133 meq/L WBC 16.8 x 103/mm3 Alb 3.2 g/dL

K 3.1 meq/L Hb 10.6 g/dL Protein, total 6.8 g/dL

Cl 109 meq/L Hct 45% Total Chol 266

HCO3 16 meq/L Plt 155 x 103/mm3 LDL 170mg/dl

BUN 40 mg/dL AST 14 IU/L Mg 2.5 mg/dL HDL 32mg/dl

Cr 1.28 mg/dL ALT 31 IU/L Triglycerides 356mg/dl

Ca 8.8 mg/dL Alk phos 78 IU/L

Glu, nonfasting 420 mg/dL Bilirubin, total 0.3 mg/dL

PO4 4.8 mg/dL PT 14.2 sec

CXR = Hyperinflation of the lungs with flattened diaphragm, no evidence of consolidation or atelectasis

_____________________________________________________________________________________

Answer the following questions based on the information above:

1) Explain the pathophysiology of diabetes type 2. (3 points)

2) What medication(s) is the patient taking for diabetes mellitus type II? (1point)

3) In understanding metabolic syndrome – explain what results support a diagnosis of metabolic syndrome. (3 points)

4) What are the similarities and differences between diabetes mellitus type I and diabetes mellitus type II. (8 points)

5) What complication of diabetes does this patient have? Explain the process of the complication. What lab results/UA results support this diagnosis? (5 points)

_____________________________________________________________________________________

Clinical Course: The patient is admitted to the telemetry floor for diabetic ketoacidosis and becomes your patient. The patient has been given potassium replacement orally and started on IV fluids and an insulin drip. After 6 hours of being under your care the patient complains of increasing shortness of breath and believes her swelling of lower extremities is worsening. You obtain vital signs:

Vital Signs: T: 99.8; HR: 110; R: 32; B/P: 172/98; O2 sat: 86% on 2 Liters O2 per NC

Stat labs and chest x-ray are obtained and an echocardiogram and EKG has been ordered.

Labs and Diagnostics:

CBC/BMP/CARDIAC ENZYMES

Na 134 meq/L K 2.9 meq/L Cl 109 meq/L HCO3 17 meq/L BUN 44 mg/dL Cr 1.5 mg/dL

WBC 16.8 x 103/mm3 Hb 10.6 g/dl / Hct45% TROP: 0.34 ng/ml CK: 102U/L CKMB: 3ng/mL

BNP 1025pg/ml Glucose 180

CXR = Hyperinflation of the lungs with flattened diaphragm, with new consolidation right lower and right middle lobe

ECHO = EF = 38% EKG = Sinus tachycardia with PVCs

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Answer the following questions based on the information above:

6) In reviewing the assessment, lab results and diagnostic testing what do you suspect is the problem? (1 point) What lab results and diagnostic tests support your suspicion? (2 points)

7) What are the contributing factors / assessment findings in the patient’s history and physical above that contribute or relate to this diagnosis? (2 points)

8) The patient is a known hypertensive on medication, but her blood pressure continues to rise. What is the pathophysiology behind her continued BP elevation? (5 points)

9) What physical findings would you look for to differentiate left heart failure from right heart failure? (2 points)

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Clinical Course: You call the hospitalist regarding the labs above and he orders: Potassium rider 40meq IV x 1 now, Decreases the IV fluids, D/C insulin drip, Start insulin sliding scale with accuchecks every 2 hours, increases oxygen to 4 Liters O2 per NC with titration to maintain SpO2 >92%, Duonebs every 4 hours and Lasix 40mg IV x 1 now. You inform him that the newest vital signs are: T:100.9; HR: 114; R: 32; B/P: 122/64. Urine output 60cc/

Basic Metabolic Profile, UA, ABG and Lactic Acid ordered:

Labs and Diagnostics:

Na 134 meq/L K 3.0 meq/L Cl 109 meq/L HCO3 17 meq/L BUN 66 mg/dL Cr 3.0 mg/dL

WBC 16.8 x 103/mm3 Hb 7.6 g/dl / Hct 55% TROP: 0.34 ng/ml CK: 102U/L CKMB: 3ng/mL

URINALYSIS

Clear, pale yellow urine; Microscopy was negative for cells, casts, pigments, and crystals

SG 1.008 (-) bacteria (+) glucose (+) protein (-) Nitrate (+) RBC many (-) WBC

BNP 1025pg/ml Glucose 180

ABG: pH= 7.30; PaCo2=12; PaO2= 89; HCO3: 18 BE: 1

LACTIC ACID: 15mmol/L

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Answer the following questions based on the information above:

10) The patient is noted to have acute kidney injury (AKI) and nephrology is consulted. Based on the patient’s diagnosis and labs, is the patient exhibiting pre-renal, intra-renal or post renal failure? (2points). How did you determine this? (3 points)

11) List the factors and that could be contributing to this patients AKI. ( 3 points)

12) Describe the key differences between pre-renal and intrarenal failure As the nurse, what would you look for on your assessment? (5 points)

13) Comorbidities such as hypertension and diabetes can affect kidney function over and above this patient’s diagnosis. What would be your expected goals for this patient at discharge to prevent a reoccurrence and readmission? (4 points)

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Clinical Course: The patient is transferred to the ICU due to the ABG results and elevated lactic acid in order to receive treatment for sepsis. The patient is intubated during the night and received 2 units packed red blood cells. The patient received Lasix 60mg IV and continues on IV fluids. In the morning following the transfer to the ICU, am labs and CXR are done. Patient has the following Vital Signs: T: 101.2; HR: 104; R: 24; B/P: 98/62; O2 sat: 98% on ventilator at 50% O2. Assessment findings: S1/S2 tachycardia regular; Edema 2+ pitting B/L lower extremities. Hyporesonnance right lower lobe, crackles bilateral lower lobes and right mid lobe.

Labs and Diagnostics:

CBC/BMP/CARDIAC ENZYMES

Na 136 meq/L K 3.6 meq/L Cl 118 meq/L HCO3 22 meq/L BUN 42 mg/dL Cr 1.3 mg/dL

WBC 16.8 x 103/mm3 Hb 9.2 g/dl / Hct 58% TROP: 0.20 ng/ml CK: 106U/L CKMB: 2ng/mL

BNP 856pg/ml Glucose 128

CXR = Right lower lobe consolidation, right mid lobe infiltrate consistent with pneumonia, left lower lobe and right lower lobe with small pleural effusion.

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Answer the following questions based on the information above:

14) What category of pneumonia is this considered? (1 points)

15) Identify 3 risk factors that predisposed this patient to pneumonia. (2 points)

16) Identify 2 clinical assessment signs and 2 lab/diagnostic results that support the diagnosis of pneumonia. (2 points)

17) Explain the pathophysiologic basis of the patients decreased pH, elevated pCO2, decreased paO2, and decreased HCO3 leading to intubation. (8 points)

18) Identify the type of abnormal breathing pattern the patient presented with when arriving at the hospital. (1 point); Explain this abnormal breathing pattern. (1 points); Why did the patient have this abnormal breathing pattern? (1 point)

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APA (5 points)

Scholarly work (5 points)

 

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