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N4810 Clinical Paperwork Rev 11/6/13

CSU, STANISLAUS B.S.N.


CLINICAL PLAN OF CARE
Patient Data
Student __LeAnna Ceglia___ Date of Care __4/16/15-4/17/15___ Room Number __N2331__ Code Status: _Full__
Pt. Initials _JA__ Gender _Male_ Age_29_ Height_60 0.01_ Weight_99.7kg__ BMI _29.73_ Spirituality _Catholic__ Ethnicity _Hispanic__
Admitting Diagnosis: ____Gunshot wound chest, flank _______________________________
Vital Signs: Temp _100.2 F_ HR _109_ RR _24_ B/P _141/82_ O2 Sat _100%_ Pain Scale & Scale Type_6, Adult Nonverbal Pain Scale__
History related to this admission __Patient has just released from local jail under the condition of being on house arrest due to gang affiliation. On
the night of 4/15/15 the patient opened the front door to his house after he heard a knock and was shot in the chest. The patients father was home
and called 911 to rush his son to the hospital. Patient was take to the ER at Mercy hospital first, then to the OR at MMC to have an exploratory
laparotomy, and eventually to ICU. Pt suffered from wound to right upper chest and exit wound to left flank, laceration to left lobe of liver, laceration
to his pancreas, laceration/hematoma to left kidney, hematoma to bladder, and fracture to left 12th rib__
Past Medical History _______________________________________________________________________________________
Admit Date _4/16/15 POD _1_
Surgical History & Date __partial pancriotomy, mediasteniostomy, gastrointestinal repair, temporal abdominal closing _
MD(s) _Dr. Coates__________

Diet __NPO______ Activity __Bedfast____


Advance Directive:
Yes ________ No __X__

Foley _X_ Feeding Tube & Rate ________


Drains/ Tubes _Chest tube, abdominal drain, endotracheal tube, naso/oral tube,
central line_
Isolation _Contact Precaution__ VS Freq _Q15min__
Glucose Monitoring _ __ DVT Prophylaxis __SCD boots __
Vascular Access:
PCA/Epidural __ _ Telemetry & Rhythm _Normal sinus rhythm____
IV Site: __R forearm_ IV Solution & Rate:_NaCl 0.9%, 10ml/hr_ Safety Considerations _Fall precautions, contact precaution_ Restraints _X__
IV Site: ___________ IV Solution & Rate: __________________ Labs for day of clinical __See lab sheet____
Dressing Changes & Frequency__midsternal dressing, central__ Scheduled Procedures __Exploratory laparotomy____
_abdominal tubing dressing, lateral abdominal tubing dressing
_Qdaily_
Procedures done this admission _Intubation, chest and abdominal x-ray,
exploratory laparotomy__
Oxygen __Ventilator_______
Respiratory Treatment: __oral suctioning, Albuterol Nebulizer Solution,
2.5mg/inhalation/Q2H PRN__
Vent Settings: _O2:_40%, VT: 0.700, Tinsp: 1.0, F 24, Supp: 15 _
Advanced Hemodynamic Monitoring & Values __ ___________________
IV Drips Medications Dosage & Rate: __Fentanyl, 7.5mL/hr___
__Midazolam, 6mg/hr__
________________________
________________________
__________________________
________________________

N4810 Clinical Paperwork Rev 11/6/13

N4810 Clinical Paperwork Rev 11/6/13

Medication
Generic & Trade Name
Dose, Route, Frequency
Acetaminophen
Tylenol
650mg/PO/Q4H PRN
650mg/rectal/Q4H PRN

Mechanism of Action
Classification
Analgesic
Produce analgesia by
inhibiting
prostaglandin and
other substances that
sensitize pain
receptors

Albuterol
AccuNeb
2.5mg/oral inhalation/Q4H
PRN

Bronchodilator
Relaxes bronchial,
uterine, and vascular
smooth muscle by
stimulating beta 2
receptors

Bisacodyl
Dulcolax
10mg/rectal/daily prn

Laxative
Stimulant laxative that
increases peristalsis by
direct effect on smooth
muscle of the
intestines by irritating
the muscle or
stimulating the colonic
intramural plexus

Patient-Specific Rationale

Nursing Considerations
(Assessment implications, side effects, reasons to hold med,
administration rate, etc)

This medication is
administered due to patient
having a fever at 100.2 F
and non-pharmaceutical
measures (light clothing, no
blankets, and room
temperature adjusted) was
not successful. Due to pt
being NPO, if this medication
is given, it would be given
ng.
Treatment ordered in case
patient is experiencing
shortness of breath,
bronchospasm, or wheezing
which can be a result from
his injuries (gunshot wound
to chest). Due to pt being
intubated, pt will receive
treatment through
endotracheal tube.
Ordered for pt to prevent
constipation due to pt being
bedfast and on pain
medication which can cause
constipation. Held because pt
lacks bowel sounds. It is also
important that the pt does not
strain since pts abdominal
cavity is open after
exploratory laparoscopy.
Also, due to pt having a
gunshot wound to chest, it is
important pt doesnt strain
due to causing potential
internal bleeding from

Have parent consult doctor before giving to child


younger than 2; for short-term use only; advise pt that
many OTC products contain acetaminophen, do not use
for marked fever, fever persisting over 3 days, or is
recurrent; high dosage, and or unsupervised long-term
use can cause liver damage; avoid alcohol; drug appears
in breast milk; monitor for S&S of jaundice
S/E: leukopenia, neutropenia, pancytopenia,
hypoglycemia, hemolytic anemia

Warn pt and stop immediately if paradoxical


bronchospasm; wait at least 2 minutes in between
multiple inhalations; use bronchodilator 1st before
corticosteroids if both ordered; do not use more than
prescribed; do not chew or crush tablets or mix with
food; use cautiously in patients with CV disorders,
hyperthyroidism, or diabetes; assess pts lungs sounds
before and after use
S/E: bronchospasm, tremor, headache, CNS stimulation,
tachycardia, palpitation, dry and irritated nose and
throat; N/V, cough wheezing, hypokalemia
Use cautiously in pts taking aspirin; stop therapy if
tinnitus occurs; avoid use before GI radiologic
procedures because drug is radiopaque and may interfere
with xrays; notify prescriber if diarrhea lasts longer than
2 days; teach pt to drink plenty of clear liquids to
prevent dehydration; tongue and stools may temporarily
turn gray-black
S/E: dizziness, muscle weakness with excessive use,
abdominal cramps, nausea, vomiting, alkalosis, fluid and
electrolyte imbalance, hypokalemia, tetany

N4810 Clinical Paperwork Rev 11/6/13

injuries.

Cefoxitin IVPB
Mefoxin
1g/IV/Q8HR

Antibiotic
Inhibits cell-wall
synthesis, promoting
osmotic instability;
usually bacterialcidal

Fentanyl IV Drip
Sublimaze
2.5-10mL/hr/IV/titrate

Opioid Analgesic
Binds with opioid
receptors in the CNS,
altering perception of
and emotional
response to pain

Hydrocodone/Acetaminophen
Norco5, 10
1-2 tabs/PO/Q4H PRN

Narcotic
Hydrocodone blocks
the receptors on nerve
cells in the brain that
give rise to the
sensation of pain.
Acetaminophen is a
non-narcotic
analgesic and
antipyretic.

This antibiotic is being


administered due to pt
possibly having an infection
as evident by pts fever
(100.2 F) and due to foreign
body entering body (gunshot
wound). Medication is also
administered as a
prophylactic after pt has
undergone surgery to prevent
surgery.
Administered to pt who
experiencing continuous pain
as evident by his injuries
(gunshot wound), surgical
procedures (opened
abdomen, opened sternum,
abdominal and chest
tubes/drains), behavior
(tearing, facial wincing, and
guarding), and scoring a 6/10
on the Adult Nonverbal Pain
Scale.

Administered to pt who
experiencing continuous pain
as evident by his injuries
(gunshot wound), surgical
procedures (opened
abdomen, opened sternum,
abdominal and chest
tubes/drains), behavior
(tearing, facial wincing, and
guarding), and scoring a 6/10

Use cautiously in pts hypersensitive to penicillin or


breast-feeding women; teach pt to report adverse
reactions or S&S of superinfections; instruct pt to report
discomfort at IV site; notify doctor about loose stools or
diarrhea; monitor for S&S of superinfection if large or
prolonged dose is administered
S/E: pseudomembranous colitis, acute renal failure,
thrombocytopenia, transient neutropenia, anaphylaxis

Contraindicated in pts intolerant to drug, hypertensive to


adhesives, opioid-nave, mucositis, brain tumors, COPD,
decreased respiratory reserve, hepatic or renal disease, or
cardiac bradyarrhythmias; S&S of overdose: CNS
depression, respiratory depression, apnea, flaccid
skeletal muscles, bradycardia, hypotension, circulatory
collapse; give drug before pt has intense pain; high dose
can produce muscle rigidity which can be reversed with
neuromuscular blockers; monitor pts circulatory,
respiratory, and urinary function and vital signs; drug
may cause constipation; watch for signs of abuse or
misuse; identify drugs that may increase fentanyl levels;
S/E: arrhythmias, deep vein thrombosis, pulmonary
embolism, apnea, hypoventilation, respiratory
depression
Assess pts pain level and check vital signs, especially
respiratory rate before, during and after administration;

N4810 Clinical Paperwork Rev 11/6/13

Hydromorphone
Dilaudid
0.2-2mg/IV/Q4H PRN

Magnesium Hydroxide
Milk of Magnesia
30mL/PO/daily PRN

Acetaminophen
works by elevating
the threshold to pain
in order for pain to be
felt, greater
stimulation of the
nerves responsible for
the sensation of pain
is necessary.
Opioid Analgesic
Binds with opioid
receptors in the CNS,
altering perception of
and emotional
response pain. Also
suppresses the cough
reflex by direct action
on the cough center in
the medulla

on the Adult Nonverbal Pain


Scale. Doctor ordering once
pt is extubated. Not given
b/c pt is had no bowel sounds
and is NPO. If medication is
given with pt being intubated,
medication will be given
through ng tube.

Laxative
Saline laxative that
produces an osmotic
effect in the small
intestine by drawing
water into the
intestinal lumen

Ordered for pt to prevent


constipation due to pt being
bedfast and on pain
medication which can cause
constipation. Pt also lacks
bowel sounds. It is also
important that the pt does not
strain since pts abdominal
cavity is open after
exploratory laparoscopy.
Also, due to pt having a
gunshot wound to chest, it is
important pt doesnt strain
due to causing potential
internal bleeding from

Administered to pt who
experiencing continuous pain
as evident by his injuries
(gunshot wound), surgical
procedures (opened
abdomen, opened sternum,
abdominal and chest
tubes/drains), behavior
(tearing, facial wincing, and
guarding), and scoring a 6/10
on the Adult Nonverbal Pain
Scale.

Contraindicated in pts who are opoid-nave; use caution


in elderly or debilitated pts as well as those with hepatic
or renal disease, hypothyroidism, Addison disease,
prostatic hyperplasia, or urethral stricture; watch for
S&S of overdose: constricted pupils, cold clammy skin,
extreme somnolence, progressing to stupor or coma,
respiratory depression, skeletal muscle flaccidity,
bradycardia, hypotension, apnea, cardiac arrest,
circulatory collapse, and death; reassess pts level of
pain at least 15-30 mins after administration; give drug
on a regular schedule; monitor respiratory and
circulatory status and bowel function; keep opioid
antagonist available (naloxone); may worsen or mask
gallbladder pain; drug may cause constipation
S/E: bradycardia, respiratory depression, bronchospasm,
sedation, hypotension, nausea, vomiting, constipation
Contraindicated in pts who are pregnant, have
myocardial damage, heart block, fecal impaction, rectal
fissures, intestinal obstruction or perforation, renal
disease, S&S of appendicitis, abdominal pain, nausea, or
vomiting; watch for S&S of overdose: blurred or double
vision, coma, dizziness, syncope, drowsiness, increased
or decreased urination, bradycardia, and dyspnea;
determine if pt has had adequate fluid intake, exercise,
and diet; monitor electrolyte levels during prolonged
use; teach pt about dietary sources of fiber, adequate
exercise, and adequate fluid intake
S/E: abdominal cramping, diarrhea, nausea, fluid and
electrolyte disturbances with daily use; laxative
dependence with prolonged use
N4810 Clinical Paperwork Rev 11/6/13

injuries. Due to pt being


NPO, if this medication is
given, it would be given ng.
Midazolam
1-10mL/hr/IV/titrate
1mg/IV/Q30min PRN

Anxiolytic
May potentiate the
effects of GABA,
depress the CNS, and
suppress the spread of
seizure activity

Anxiolytic administered to pt
to decrease agitation and
promote sedation. These
behaviors include pt grabbing
and pulling at endotracheal
tube when not sedated.
Sedation will also help the pt
rest which will help the
healing/recovering process.

Pantoprazole
Protonix
20mg/PO/daily

Antiulcer
Inhibits proton pump
activity by binding to
hydrogen-potassium
adenosine
triphosphatase to
suppress gastric acid
secretion

Potassium Chloride
K-Dur
10 mEq/IV/PRN

Potassium Supplement
Replaces potassium
and maintains
potassium levels

An antiulcer medication used


to prevent ulcers from
developing in stomach since
pt is under a lot of stress of
being in the hospital,
suffering from trauma, and
being on a ventilator. Due to
pt being NPO, if medication
is to be given, it will be given
through ng tube.
Although pts potassium
level is not low, this
medication is ordered in
order to prevent hypokalemia
due to possible electrolyte
imbalance from pts injuries
and surgery.

Ondansetron
Zofran
4mg/IV/Q4H prn

Antiemetic
May block 5-HT3 in
the CNS in the

Due to pt being intubated and


sedated, it is crucial that pt
does not vomit due to risk of

Medication should only be administered by persons


specifically trained in the use of anesthetics and the
management of respiratory effects of anesthetics; S&S
of overdose: excessive sedation, somnolence, confusion,
impaired coordination, diminished reflexes, coma,
altered viral signs; have oxygen and resuscitation
equipment available in case of severe respiratory
suppression; monitor blood pressure, heart rate and
rhythm, respirations, airway integrity, and arterial
oxygen saturation during procedure
S/E: apnea, oversedation, drowsiness, variations in blood
pressure and pulse rate, decreased respiratory rate,
hiccups
Prolonged use may cause low magnesium levels;
monitor magnesium levels; monitor pt for S&S of low
magnesium level; low magnesium levels cause abnormal
heart rate or rhythm, palpitations, muscle spasms,
tremors, or seizures
S/E: anxiety, headache, pharyngitis, abdominal pain,
urinary frequency, hyperglycemia, arthralgia, bronchitis

Monitor ECG and electrolyte levels; monitor renal


function; many adverse reactions may reflect
hyperkalemia; use cautiously in pts with renal
impairment or cardiac disease; contraindicated in pts
with severe renal impairment with oliguria, anuria or
azotemia; Overdose S&S include ECG changes,
weakness, flaccidity, respiratory paralysis, cardiac
arrhythmias, death
S/E: arrhythmias, heart block, cardiac arrest,
hyperkalemia, respiratory paralysis
Contraindicated for use with apomorphine; monitor pt
for ECG changes such as prolonged QT intervals; use
cautiously in pts with hepatic impairment; monitor pt
N4810 Clinical Paperwork Rev 11/6/13

Enalaprilat
Vasotec
2.5mg/IV/Q6H PRN

Propofol
Diprivan
15mL/hr/IV/titrate

chemoreceptor trigger
zone and in the
peripheral nervous
system on nerve
terminals of the vagus
nerve
Antihypertensive
May inhibit ACE,
preventing conversion
of angiotension I to
angiotensis II, a potent
vasoconstrictor
Hypnotic
Unknown. Rapidacting IV sedative
hypnotic

aspirating.

for electrolyte imbalances such as hypokalemia or


hypomagnesia; monitor liver function tests; monitor pt
for any difficulty breathing
S/E: arrhythmias, hypoxia, dizziness, fatigue, chest pain,
constipation, diarrhea, urine retention, chills, pruritus

Administered to pt due to
blood pressure being high at
141/82 and gradually
increasing.

Use cautiously in pts with renal impairment: S&S of


overdose: hypotension; closely monitor pts blood
pressure; monitor CBC with differential counts before
and after therapy; monitor potassium levels and intake
S/E: asthenia, headache, hypotension, chest pain,
diarrhea, nausea, abdominal pain, vomiting, decreased
renal function, bone marrow suppression, angioedema
Hypnotic administered to pt
Use cautiously in pts who are hemodynamically
to decrease agitation and
unstable; monitor for S&S of overdose:
promote sedation. These
Cardiorespiratory depression; urine may turn green if
behaviors include pt grabbing used for prolonged sedation; continuously monitor vital
and pulling at endotracheal
signs; reduce other lipid products if given with this
tube when not sedated.
medication; monitor pt at risk for hyperlipidemia for
Sedation will also help the pt elevated triglyceride levels; assess pts CNS function
rest which will help the
daily to determine minimum dose needed
healing/recovering process
S/E: bradycardia, apnea, respiratory acidosis, dystonic or
choreiform movement, hypotension, hypertension,
decreased cardiac output, hyperlipidemia

CALIFORNIA STATE UNIVERSITY, STANISLAUS


MEDICATION WORKSHEET

N4810 Clinical Paperwork Rev 11/6/13

LABORATORY DATA

LABS

Normal
Range
(Fill in Hospital
Norms)

RESULT RESULT RESULT


1
2
3
(4/16, 0500)

(4/17, 0830)

CBC
WBC
RBC

4.0-11.0
4.4-6.0

9.3
3.24

10.9
3.66

Hemoglobin

13.5-18.0

9.9

11.1

Hematocrit

40.0-52.0

28.9

30.9

MCV
MCH
MCHC
RDW
PLT COUNT
WBC DIFF
NEUTROPHIL %

80-100
27.0-33.0
31.0-36.0
<16.4

89
30.6
34.7
13.5

84
30.3
35.9
14.6

82

81

49-74

Reason for abnormal lab values r/t


diagnosis & nursing implications

(date &
time)

Although the RBC levels are below the


normal limits, this is an expected
finding/level due to pt experiencing
injuries that cause bleeding (gunshot
wound) as well as possible loss of
blood during surgical procedures.
Monitor pt for further S&S of bleeding
or possible hemorrhaging.
Although the hemoglobin levels are
below the normal limits, this is an
expected finding/level due to pt
experiencing injuries that cause
bleeding (gunshot wound) as well as
possible loss of blood during surgical
procedures. Monitor pt for further
S&S of bleeding or possible
hemorrhaging.
Although the hemoglobin levels are
below the normal limits, this is an
expected finding/level due to pt
experiencing injuries that cause
bleeding (gunshot wound) as well as
possible loss of blood during surgical
procedures. Monitor pt for further
S&S of bleeding or possible
hemorrhaging.

Although the neutrophil levels are


increased, this is expected due to pt
suffering from trauma of having a
gunshot wound. His injuries can also
cause physical and emotional stress
which can increase the pts neutrophil
levels. Promote rest by use of sedation
and relaxation techniques.

BANDS %
N4810 Clinical Paperwork Rev 11/6/13

LYMPHOCYTE%

26-46

MONOCYTE %
CHEMISTRY
Sodium
Potassium

136-145
3.5-5.1

145
5.5

142
3.5

Chloride

98-107

123

114

CO2(bicarb)venous

21-32

13

19

Glucose

70-90

148

90

Although the lymphocytes levels are


below the normal limits, this is an
expected finding/level due to pt
experiencing injuries that cause
bleeding (gunshot wound) as well as
possible loss of blood during surgical
procedures. Monitor pt for further
S&S of bleeding or possible
hemorrhaging.

Since pt was hyperkalemic, but is now


within normal limits, continue to
monitor pt for further S&S of
hyperkalemia such as muscle fatigue,
weakness, paralysis, abnormal heart
rhythms, and nausea. Pts potassium
level could have been increased due to
pt receiving potassium chloride via IV.
This lab level can also be altered due to
massive cell destruction due to his
gunshot wound. Continue to monitor
pt for S&S of hyperkalemia.
This level is increased to due pt
suffering respiratory alkalosis as
evident by his increased pH at 7.457
and decreased PCO2 at 7.26. This lab
level can also be increased due to
possible excessive infusion of D5W
solution which the pt is receiving due
his risk for electrolyte imbalance and is
compatible with his blood transfusions.
Monitor pt for S&S of hypernatremia
and edema as well as for signs of
hyperventilation or change in work of
breathing.
This level is slightly decreased
possibly due to pts gunshot injuries.
More specifically, CO2 can be
decreased if ones kidneys are not
working sufficiently and the pts
suffers from a laceration/hematoma to
his left kidney. Monitor pts kidney
function tests and urine output.
Although glucose levels are now
within normal limits, his levels were
originally increased. This is an
expected finding due to pt suffering
from injuries and being under stress.
N4810 Clinical Paperwork Rev 11/6/13

Calcium

8.2-10.2

6.6

7.3

phosphorus
Magnesium

1.8-2.4

1.2

1.8

HDL
LDL
Cholesterol
Triglycerides
LIVER PANEL
Total protein

Levels are also expected to increase


due to pt being on D5W. Although pt
is not diabetic and his levels are now
within normal limits, monitor pt for
signs of hyperglycemia due to pt still
being under stress and suffering from
his injuries.
This level may be low for a couple of
different reasons. The first reason
could be due to his albumin levels
being low because hypoalbuminemia
can cause calcium levels to decrease.
Also, the pt has sustained injuries to
kidneys and his pancreas due to his
gunshot wound. With that being said,
when the kidneys are not functioning
efficiently and it can be assumed that
there is some inflammation around his
pancreas, these conditions can cause
calcium levels to decrease. Monitor
pts kidney function tests and urine
output. Also assess for any excess pain
or swelling around pts abdomen and
back that can be associated with the
pts kidneys and pancreas.
Although pts magnesium level was
originally low, but is now within
normal limits, this could have been due
to pt being at risk for electrolyte
imbalance due to potential blood loss
from his injuries and surgery. Since pt
has been receiving Magnesium Sulfate
with Dextrose via IV, his magnesium
level has remained within normal
limits. However, the pt will be
continuously monitored for
hypmagnesia such as Muscle
weakness muscle tightness, tremors,
twitches, irritability, numbness and
tingling, confusion, seizure, and
increased or irregular heart rate.

0-150
6.4-8.2

3.0

This lab level can be reduced possibly


for two reasons. The first reason is by
suffering from fluid third space losses
N4810 Clinical Paperwork Rev 11/6/13

Albumin

3.2-4.7

1.6

Bilirubin Total
Alk phosphatase
AST

0.1-1.1
26-137
0-37

0.7

ALT

0-60

102

92

due to his gunshot wounds. The


second possible reason is if the pt is
overhydrated due to his continuous
administration of D5W, having his
bladder irrigated and being on IV drips.
This level is also expected to decrease
after a pt has been in surgery. Pt will
be monitored and assessed for edema
and other signs of being overhydrated
such as SOB, increased respiratory
rate, increased and bounding pulses,
labored breathing, moist skin, crackles
auscultated in lungs, JVD, weight gain,
S3 noted with heartbeat, etc.
This lab level can be reduced possibly
for two reasons. The first reason is by
suffering from fluid third space losses
due to his gunshot wounds. The
second possible reason is if the pt is
overhydrated due to his continuous
administration of D5W, having his
bladder irrigated and being on IV drips.
This level is also expected to decrease
after a pt has been in surgery. Pt will
be monitored and assessed for edema
and other signs of being overhydrated
such as SOB, increased respiratory
rate, increased and bounding pulses,
labored breathing, moist skin, crackles
auscultated in lungs, JVD, weight gain,
S3 noted with heartbeat, etc.

Pt may be experiencing inflammation


of the liver or possible hepatic necrosis
which can be due to his injuries that he
sustained to the liver. According to the
pts x-ray, he suffered from a laceration
to the left lobe of his liver. Also, AST
levels may increase with hepatic
surgery which the pt had on 4/16/15 to
fix the laceration. Pts LFTs will be
continuously monitored.
This level is mildly increased due to
the trauma to his liver. According to
the pts x-ray, he suffered from a
laceration to the left lobe of his liver.
Damage to the liver causes a release of
an enzyme into the bloodstream,
elevating the ALT levels. Continue to
N4810 Clinical Paperwork Rev 11/6/13

monitor patients LFTs.


Lipase
Amylase
Ammonia
Lactate
Serum Ketones
CARDIAC PANEL
CPK
CPK-MB

Comment [sb1]: You say pt. has pancretitis how


come you dont have elevagd

Normal
Range
(Fill in Hospital
Norms)

Troponin
Myoglobin
BNP
COAGULATTION
PT

INR ratio

PTT
Fibrin level
Bleeding time
D-Dimer
UA collection type
Urine color

12.1-15.3

21.4

17.7

0.9-1.1

2.0

1.5

Amber
yellow

dark
amber

light pink

The pts PT level may be increased due


to his blood transfusions due to his
blood loss from his injuries and
surgery. By having blood transfusions,
coagulation is inhibited by the
anticoagulant in the banked blood.
Also, alcohol intake can prolong PT
times. With that being said, the pts
drug test came back positive for
alcohol in his system when he was
admitted to the hospital. The pt will be
continuously monitored for S&S of
bleeding and possible hemorrhaging.
The pts PT level may be increased due
to his blood transfusions due to his
blood loss from his injuries and
surgery. By having blood transfusions,
coagulation is inhibited by the
anticoagulant in the banked blood.
Also, alcohol intake can prolong PT
times. With that being said, the pts
drug test came back positive for
alcohol in his system when he was
admitted to the hospital. The pt will be
continuously monitored for S&S of
bleeding and possible hemorrhaging.

Pts urine color ranged from dark


amber to eventually to light pink due to
blood being in pts urine. This could
N4810 Clinical Paperwork Rev 11/6/13

Urine appearance

clear

Blood
clots
visible

1.020

Urine Ph
Urine glucose

1.0031.035
5.0-8.0
Negative

7
Trace

Urine bilirubin
Urine blood

Negative
Negative

Negative
Small

Urine Ketones
Urine Nitrites
Urine Protein

Negative
Negative
Negative

Negative
Negative
>500

Urine Leukocytes
URINE MICRO
WBC HPF
RBC HPF
Nitrate HPF
Epithelial
Bacteria
Mucous

Negative

Negative

Specific gravity

Blood
clots
visible

be due to pt possibly suffering from


internal bleeding of the kidneys and
bladder. Pts urine color and output
will be continuously monitored. Pts
urine color is gradually lightening due
to pt receiving continuous bladder
irrigation.
Pts urine appearance has visible blood
clots due to pt possibly suffering from
internal bleeding of the kidneys and
bladder. Pts urine appearance and
output will be continuously monitored
as well as continuously irrigated until
blood clots are no longer visible.

This is an expected finding due to pt


suffering from injuries and being under
stress. Levels are also expected to
increase due to pt being on D5W.
Although pt is not diabetic, he will be
monitored for signs of hyperglycemia
due to pt still being under stress and
suffering from his injuries.
Blood is found in the urine due to pt
possibly suffering from internal
bleeding of the kidneys and bladder. Pt
urine color and appearance will be
continuously monitor as well as
monitoring pt for any further signs of
excessive bleeding. Pt is also receiving
continuous bladder irrigation.

Protein is a subtle indicator of kidney


function. Having protein in the urine is
an expected finding due to pt suffering
from a laceration/hematoma to his left
kidney.

N4810 Clinical Paperwork Rev 11/6/13

URINE CULTURE
CSF
WBC
RBC
Glucose
Protein
Culture
Blood Cultures
Stool Cultures
Nasal Cultures
ABG(FIO2 + device)
pH

7.3507.450

7.286

7.457

PO2
PCO2

80-100
35-45

488
27.3

102
27.6

Bicarbonate

20-26

12.7

19.1

Oxygen Saturation
Anion gap
Lactate

95-100

98

98

pH level is slightly increased due to


pts increased respirations. His
respirations may be increased due to
pain from his injuries and surgery as
well as due to anxiety and stress from
his condition and being in the hospital.
Pts work of breathing and oxygen
level will be monitored. Also, pt will
be assessed for and administered pain
and sedative medication as necessary to
promote rest and relaxation.
This lab level can be decreased due to
couple of reasons including the pt
experiencing pain due to his injuries
and surgery. Pt may also be
experiencing some anxiety and
agitation due to condition. Pt may also
be experiencing hypoxemia which is
suggested due to his increased
respiratory rate. Pts work of breathing
and oxygen level will be monitored.
Also, pt will be assessed for and
administered pain and sedative
medication as necessary to promote
rest and relaxation.
Since it is suspected that pt is
experiencing respiratory alkalosis
(increased pH and decreased PCO2),
normally the kidney would excreted
increased amounts of bicarbonate in
order to lower the pH. However, due
to the kidney being injured, it may not
be able to produce sufficient amount of
bicarbonate.

N4810 Clinical Paperwork Rev 11/6/13

DIAGNOSTIC DATA

ECG
X ray

Student Name: _LeAnna Ceglia___

Normal Sinus Rhythm


Chest x-ray: no pneumothorax, no metabolic
foreign body, good tube placement, fracture to
left 12th rib, gunshot to right anterior chest
Abdominal x-ray: no specific bowel gas
problem, no free air noted, no metallic foreign
body, laceration to left lobe of liver, laceration to
pancreas, laceration/hematoma to left kidney
with surrounding blood , hematoma to bladder,
gunshot exit left flank

Angiography

NOTE: This outline of labs and diagnostics is to be organized by each student it is NOT all inclusive
you must decide what labs are important. Not all labs on this list will be found on each patient.

N4810 Clinical Paperwork Rev 11/6/13

2. Ineffective Breathing Pattern


Data to Support:
Pt had abdominal surgery making pts breaths tachypnic
at 24 RR and shallow due to pain
Pts RR would also increase and become shallow when
starting to come out of sedation
Pt potentially experiencing respiratory alkalosis as
evident by pH increased at 7.457 and PCO2 decreased
at 27.6
Breath sounds diminished at bases
Interventions:
Auscultate breath sounds
Monitor pts O2 saturation
Monitor pts respiratory rate, depth, and ease and
pattern
Monitor pts ventilator settings
Use calming techniques to decrease pts resp. rate
Fentanyl was administered to pt to help with pain
related to injuries and surgery that could affect pts
breathing pattern
Propofol was increased to keep pt in sedated state to
prevent him from fighting the ventilator
Monitor blood gas values
Continue to monitor for symptoms of hyperventilation

3. Electrolyte imbalance
Data to Support:
Pt experiencing possible hypervolemia
evident by general edema 1+
Pts chloride level high at 114
Pts albumin level is low at 1.6
Pts kidney function is decreased due to
laceration/hematoma to left kidney
Pt being administered D5W continuous
Pt having continuous bladder irrigation
pH slightly elevated at 7.457
PCO2 decreased at 27.6
Bicarbonate decreased at 19.1
Interventions:
Monitor vital signs
Monitor cardiac rhythm and rate
Monitor I/O
Monitor pts respiratory status
Review/monitor labs
Completed pain assessment
Monitor pts edema

Concept Mapping
1. Ineffective Airway Clearance
Data to Support:
Pt intubated
Pt sedated
Breath sounds diminished at bases
Pt only able to gag when experiencing excess
mucous/sputum
Interventions:
Pt suctioned prn
Yanker kept at pts bed side
Auscultate breath sounds q 1-4 hrs
Monitor respiratory patterns
Monitor blood gas values and O2 saturation
Position pt to optimize respiration
Make sure pt receives respiratory treatment such as
his Albuterol.

Chief Medical Diagnosis: Gunshot wound chest,


flank
Priority Assessments:
VS: Pt demonstrating ineffective breathing,
electrolyte imbalance, and infection
O2 Sat: pt on ventilator
Breath Sounds: pt intubation and being sedated
Bowel Sounds: pt experiencing absent bowel sounds
Lab values: pt experiencing potential electrolyte
imbalance
Mental status: monitor for change in behavior which
can be due to bleeding, lack of oxygen, sedation,
hypervolemia, electrolyte imbalance, infection or
increased body temperature

5. Dysfunctional Gastrointestinal Motility


Data to Support:
Pt has absent bowel sounds in all 4 quadrants
Pts abdomen is firm
Pt had abdominal surgery
Pt NPO; only receiving IV fluids
Pt on pain medication
Pt immobile
Interventions:
Monitor pt for abdominal distention
Auscultate for bowel sounds
Palpate abdomen
Check skin turgor to assess for fluid deficit

Student Name: LeAnna Ceglia__

4. Impaired tissue integrity


Data to Support:
Pt has a gunshot wound to chest and flank
Pt had abdominal and chest surgery with open
packing
Pt has chest and abdominal tubes/drains
Interventions:
Assess and monitor the site of impaired tissue
integrity
Monitor status of the skin around the wound
Have wound specialist change dressing once a
day
Assess dressing sites
Assess the skin and tissue if affected by the tape
of the dressing
6. Risk for Infection
Data to Support:
Pt had foreign item pierce his body
Pt had abdominal surgery
Pts abdomen is left open with special packing
Pt has a fever at 100.2F
Pt has a foley catheter
Pt has 2 chest tubes and a central line
Pt is intubated
Interventions:
Use appropriate hand hygiene
Assess wounds and surrounding skin for further
signs of infection
Assess skin around tubes and drains
Monitor pt for S&S of a UTI due to foley
catheter
Monitor vital signs such as temperature
Monitor and report lab values such as WBC
Cefoxitin administered

N4810 Clinical Paperwork Rev11/06/13

Problem Evaluation
Problem #
1

Evaluation of Patient Response


Pts gagging deceases and pt appears more comfortable and at ease after suctioning occurs
Pts breath sounds appear diminished at base bilaterally
Pt appears to be breathing slightly shallow and at an increased rate of 24 breaths/min
Pts blood gas values support pt suffering from respiratory alkalosis
Pts O2 saturation remaining within normal limits at 100%
Pt appeared more comfortable and breathing with more ease when pulled up in bed, sitting with
HOB between 30 and 45 degrees
Pt is cooperative with respiratory treatment and his work of breathing appears to decrease after the
treatment
Breath sounds continue to be diminished at base
O2 saturation remains at 100%
Pt responded well to calming techniques. They decreased his resp. rate and increased depth of
breaths
Pt appeared more comfortable once Fentanyl was administered including having a decreased work
of breathing and no longer shallow breaths.
Pts respiratory rate eventually decreased to about 16 breaths/min and appeared calm with the use
of Fentanyl, Propofol and calming techniques
Pts blood gas values unable to assess and compare due to new lab results not in during my
clinical shift
Pts vital signs begin high at 100.2 F, 109 HR, 24 RR, and 141/82 B/P. However, after pain and
blood pressure medication are administered and calming techniques are used, the RR decrease to
16 RR and the B/P decreases to 119/82. O2 sat remains stable at 100%. Fever interventions were
used, however, temperature still remains high.
Pts cardiac rhythm remains normal sinus rhythm (after calming techniques and pain medication)
Pts respiratory rate was decreased to 16 after pain and sedative medication administered and
calming techniques used
Patient scored a 6/10 on adult nonverbal pain scale. However, after fentanyl was administered, pt
scored a 0/10.
Pts edema remained the same
Pts total intake including IV administration, blood administration and catheter irrigation was
16,133 mL. Pts total output was 10,732mL.
Skin appeared pink, moist, and healing properly
Skin around the wounds did not appear warm, red, or have any inflammation
Dressing sites were all dry and intact and secured properly with appropriate tape
Wound specialist came during shift to change and assess wounds.
Skin did not appear to be affected by the tape used.
Pts abdomen firm but no signs of distention
Pt continues to lack bowel sounds
Pt tenses and guards with abdomen palpation due to injuries and surgery
Pts skin turgor is intact and shows no signs of fluid deficit

N4810 Clinical Paperwork Rev11/06/13

Wounds and surgical sites appeared to be pink, moist, and healing properly
Skin around wounds and surgical sites did not appear warm, red, or have any inflammation
Skin around tubes and drains appeared dry, intact, with no signs of infection
Pt showed no S&S of a UTI
Pts temperature was above normal limits and was being treated with Acetaminophen, light-weight
clothing, and room temperature control
WBCs were within normal limits
Pt tolerated administration of antibiotic (Cefoxitin) appropriately.

N4810 Clinical Paperwork Rev11/06/13

Student Clinical Self-Appraisal


EXAMPLE
Weekly (turn in with Care Plan/Map)
Student _LeAnna Ceglia__ Course N4810_____ Instructor _Sherri Brown_
Instructions: Please evaluate your performance during clinical today using the following
concepts:
Client Advocate
Critical Thinking
Self-Initiated
Professional Accountability
Leadership
Nursing Process

Professional Demeanor
Communication/rapport
Technical skills
Organized
Well-prepared
Comprehensive Assessment

Areas of Strength Today (Date)


Critical thinking: My nurse on my second day of taking
care of my patient would ask me questions as to what I
would do next for my patient, ask me why I would perform
the tasks that I had chosen and also gave me certain
scenarios in which he would ask me what I would do in
such situations. Although I was originally nervous not
wanting to look unintelligent, I was, overall, proud of
myself. Once I calmed down and could critically think
about the situation and the rational, I was able to provide
good answers and evidence to support my actions.
Educator: The family of the patient came to visit him both
days and was there throughout the shift. I could tell they
did not know what was going on and appeared very
uneasy. To help ease the anxiety and make them feel more
involved/knowledgeable, I would tell them what I was
doing with their loved one, why I was doing it, and was
open with the questions they had for me. By the end of my
shift, they asked me questions on their own and appeared
much more at ease.
Technical Skills: I felt fairly competent in my assessment
skills and found myself performing technical skills such as
hanging IV medications, etc. with more confidence and less
fumbling. Also, I was happy that my nurse showed me how
to draw blood and for the second time, she had me talk her
through the steps as far as what equipment I would need
and what steps I need to take. I was proud that I
remembered exactly how to do it by the second time.

Flexible
Coordinator of Care
Team Player
Educator
Ability to Prioritize
Knowledgeable

Areas Needing Growth-Include plan of


improvement
Self-Initiating: I felt that I was not very confident the
first day when it came to self-initiating. I made it clear
to my nurse, on the first day that I wanted to be involved
in doing as much for the patient, if not all, that I could.
Unfortunately, my nurse was having a rough morning
and for the first few hours did most of the care herself.
Not wanting to make her mood worse, I just watched and
tried helping when appropriate. Fortunately, by the end
of the day, my nurse began to teach me things and have
me perform some skills. However, it was not until the
second day that I felt really hands-on when it came to
patient care.
Well-prepared: I did not feel well-prepared for my
patient at the very beginning of my clinical rotation.
Originally, I had chosen another patient who was
transferred to the floor the morning I was supposed care
for him. Therefore, I had no information on the patient
that I was newly assigned. It was not a problem because
I was able to eventually catch up and look up the
information I wanted. However, during report, I had so
many questions running through my head and I could not
wait to get onto the computer to look up his information.
Organization: This patient was very different than the
patient I had taken care of during my first rotation on
ICU. Not only was I a lot busier, but my nurse was also
more hands-on. I felt that it was a great learning
experience and found myself constantly busy. However,
N4810 Clinical Paperwork Rev11/06/13

since we were so busy, I found myself struggling a little


due to not having the time to stop, think, and prioritize
for myself.

Good job one thing I would encourage you to keep working on labs and what they are
evaluating.

N4810 Clinical Paperwork Rev11/06/13

N4810 Clinical Paperwork Rev11/06/13

Student Name: _____________________________________________ Date: ____________

Clinical Instructor: ______________________

Instructions: Attach a copy of this form to the back of each of you Clinical Plan of Care/Maps for grading purposes.
Grading Rubric:
1.

Patient Data includes:


a. Health history
b. All blanks and/or issues are addressed

20 points possible _20____

2.

Each medication includes:


a. Name
b. Rationale
c. Side effects
d. Nursing implications-specific to this patient

20 points possible _20____

3.

Lab Diagnostics
a. Test
b. Results
c. Implications & Teaching

10 points possible _5____(work on you

4.

Problem Identification includes


20 points possible ___10__
a. Correctly lists individualized needs
b. Correctly identifies problems
c. Problems are prioritized and numbered, each problem in priority of importance
d. Map includes at least five physiological problems, discharge planning and patient education
e. Each problem includes:
i. Nursing diagnosis
ii. Data to support
iii. Medication
iv. Nursing treatment (interventions)

5.

Planned interventions includes


a. Interventions appropriate
b. Correctly prioritizes interventions
c. Assessments performed
d. Communication
e. Patient teaching
f.
Discharge planning

10 points possible __10___

6.

Evaluation of Interventions includes


a. Evaluates physical interventions
b. Evaluates teaching

10 points possible _10____

7.

a.
b.

10 points possible _10___

Priority Assessments are appropriate to diagnoses


Clinical Paperwork is complete
Total Points

__________95___/100 = ____%

N4810 Clinical Paperwork Rev11/06/13

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