JACKSON COMMUNITY COLLEGE

NUR 171 SUPPORTIVE EDUCATIVE NURSING

PREPARATION FOR SAFE PATIENT CARE

Student Name Amy Tillman

Date 3/31/16-4/1/16

Rev 06.25.2012

DAY ONE PREPARATION - Critical Thinking Summary

Patient Room Number _______ Age _____ M/F Male ___ CODE Status Full __________

Primary Medical Diagnosis Reason for Admission Atrial Fibrillation

Secondary Medical Diagnoses List all that impact patient’s care Osteomylitis, Type 2 Diabetes Mellitus, Pulmonary embolism, Hypertension, Coronary artery disease, acute anemia

Nursing Care Plan for PRIORITY Physiological Nursing Diagnosis

Nursing Diagnosis in PES Format Patient Expected Outcome (measurable and with time frame)

Individualized & Prioritized Nursing Interventions with Referenced Evidence/Rationale

P Risk for decreased cardiac tissue perfusion

Patient will be free from chest and Radiated discomfort as well as Associated symptoms related to Acute coronary syndromes

1.Assess: Assess for symptoms of coronary Hypoperfusion

and possible ACS including chest Discomfort (pressure, tightness, crushing, squeezing, dullness, or achiness), with or

without radiation (or originating) in the back, neck, jaw, shoulder, or arm discomfort or numbness; SOB; associated

diaphoresis; dizziness, lightheadedness, loss of consciousness;

nausea or vomiting with chest discomfort, heartburn or indigestion; associated anxiety. Rationale-These symptoms

are signs of decreased cardiac perfusion and acute coronary syndrome such as UA, NSTEMI ,or STEMI. A physical

assessment will aid in assessment of extent, location and presence of, and complications resulting from a MI. It will

promote rapid triage and treatment. It is also important to

assess if the client had a prior stroke. (Akley, Ladwig pg. 188)

E atrial fibrillation 2. Intervene: Administer nitroglycerin tablets sublingually as

ordered, every 5 minutes until chest pain is resolved while also

monitoring the blood pressure for hypotension, for a maximum of 3 doses as ordered. Administer nitroglycerin

paste or intravenous preparations as ordered. Rationale: Nitroglycerin causes coronary arterial and venous dilation, and

at higher doses arterial dilation, thus reducing preload and afterload and decreasing myocardial oxygen demand while

increasing oxygen delivery. (Ackley, Ladwig pg. 189)

S aeb altered heart rhythm and EKG results?

AEB Patient understanding of disease process

3.Teaching: Teach client about any medications prescribed.

Rationale: Medication teaching includes the drug name, its

purpose, administration instructions such as taking it with or

without food, and any side effects to be aware of. Instruct the client to report any adverse side effects to his/her provider.

(Ackley, Ladwig pg. 190)

Defining Characteristics Use Ackley text

book – did you pick the correct diagnosis?

Risk factors include- hypertension, hyperlipidemia, diabetes mellitus, lack of knowledge of modifiable risk factors (smoking, inactive lifestyle). (Ackley, Ladwig pg.187)

4.Discharge: Upon discharge, educate clients about low

sodium, low saturated fat diet, with consideration to client

education, literacy and health literacy level. Rationale:

Reduction of risk factors aid as primary and secondary prevention of coronary artery disease. ATP III guidelines

recommend that saturated fats be kept to less than 7% of calories and cholesterol under 200mg/day when LDL is above

goal. A Cochrane review recommended that there be a permanent reduction in saturated fats and replacement with

unsaturated fats to decrease atherosclerosis. (Ackley, Ladwig

pg.191)

Potential Complications If this patient’s condition were to worsen, what would be the most likely reason? -Atrial fibrillation not controlled -infection not controlled -patient fall related to decreased sensation in lower extremities -blood glucose levels not controlled -pain not controlled

How will you be vigilant in monitoring for and preventing this complication?

-checking vital signs and apical pulse -helping with any ambulation -performing accuchecks -evaluating pain levels

What will you do if it happens?

Call Bill and the supervising nurse

---SCHEDULE PROCEDURES CARE PATHWAYS

How will you organize your time? (Report, medications, ambulation, bath, charting, procedures, etc.)

What procedures do you have to do? Be ready! (Catheters, injections, blood glucose

monitoring, dressing changes, etc.)

Is the patient on a Care Pathway? Attach pathway and/or agency PMP. (What do you

need to do Day 1 and Day 2 according to the path or management plan?)

Listen to report, take vital signs, pass Blood glucose, dressing changes, Refer to patient cardex

Medications, complete head to toe Heparin injections

Assessment, evaluate plan of care

PATHOPHYSIOLOGIES

Primary Diagnosis Pathophysiology Atrial fibrillation – disorganized electrical activity of the atrium. The nodes in the atrium keep firing causing multiple contractions of that are not effective. Typically occurs with other types of cardiac or vascular problems. The atrial contraction rate can be up to 350-600 beats per minute. Medical Surgical Nursing Ninth Edition textbook Author Sharon Lewis Reference – Med/Surg or Patho text (less than 5 years old):

o Textbook S&S - some patients be asymptomatic and only find out through examination. Palpitations, fatigue, shortness of

breath and chest pain are other symptoms. Also dizziness and confusion. –Mayoclinic.org o Patient’s S&S – patient currently has regular rhythm post cardioversion. Experiences chest pain and shortness of breath.

Secondary Diagnosis Pathophysiology Osteomyelitis- infection of bone, bone marrow and surround tissue. Can be caused by either direct or indirect entry. Causes from infection in the blood or a break in the skin. As the infection occurs, pressure builds up inside the bone which can cut of blood supply and cause necrosis. The bone then dies and breaks off. Medical Surgical Nursing Ninth Edition textbook Author Sharon Lewis Reference – Med/Surg or Patho text (less than 5 years old):

o Textbook S&S -symptoms include, fever, chills, irritability, pain, swelling, warmth and redness (inflammation) in area, fatigue

Mayoclinic.org

o Patient’s S&S – patient fatigued, lower extremity paraplegia

Secondary Diagnosis Pathophysiology Type 2 Diabetes Mellitus –Occurs when the pancreas produces endogenous insulin but it is not properly used by the body tissues, or the pancreas cannot make enough. The body can develop insulin resisitance. Most important risk factor is obesity but family history is also a factor. Medical Surgical Nursing Ninth Edition textbook Author Sharon Lewis Reference – Med/Surg or Patho text (less than 5 years old):

o Textbook S&S increased thirst and hunger, weight loss, fatigue, vision changes, and slow healing wounds

Mayoclinic.org

o Patient’s S&S – elevated blood glucose levels, fatigue, slow healing

Secondary Diagnosis Pathophysiology Hypertension- having systolic blood pressure over 140mmHg and diastolic over 90mmHg. When a patient consistently has blood pressure measured at this number they are considered hypertensive. It can be either primary or secondary hypertension based upon some other condition causing it. Medical Surgical Nursing Ninth Edition textbook Author Sharon Lewis Reference – Med/Surg or Patho text (less than 5 years old):

o Textbook S&S - most patients are asymptomatic, occasionally patients may have headaches, nosebleeds and shortness of

breath. Usually found through examination. Mayoclinic.org o Patient’s S&S – shortness of breath, elevated systolic blood pressure

Secondary Diagnosis Pathophysiology Coronary Artery Disease- caused by atherosclerosis in the coronary arteries. Involves hardening of the fat deposits within the vessels. The endothelium of the artery will become inflamed from different factors. This inflammation can lead to plaque rupture. Medical Surgical Nursing Ninth Edition textbook Author Sharon Lewis Reference – Med/Surg or Patho text (less than 5 years old):

o Textbook S&S- chest pain, shortness of breath, and heart attack mayoclinic.org

o Patient’s S&S – chest pain, shortness of breath, elevated CRP levels

Secondary Diagnosis Pathophysiology Acute Anemia - deficient number of erythrocytes, hemoglobin or hematocrit within the blood. Many different forms and causes. Can lead to tissue hypoxia. Medical Surgical Nursing Ninth Edition textbook Author Sharon Lewis Reference – Med/Surg or Patho text (less than 5 years old):

o Textbook S&S -fatigue, weakness, shortness of breath, dizziness, chest pain, cold hands and feet, headache, irregular

heartbeats. Mayoclinic.org o Patient’s S&S – low levels of Red Blood cells, Hemoglobin, hematocrit, RDW-SD, shortness of breath, chest pain, cold

extremities, fatigue

Allergies and usual reactions: PCN, Sulfa, Motrin

Generic/Brand Name and Class

Normal Dose Patient’s Dose Times to Give

Drug Action Why ordered for this patient?

Items to check before giving;

when to hold

Two common side effects

You know med is working when:

Lipitor (Atorvastatin)

10-80mg by mouth daily

80mg daily in the morning

Lowers cholesterol Hyperlipidemia Liver function tests, Creatinine

levels

Headache Nausea

Cholesterol levels are WNL

Tums (calcium

carbonate) Antacid

2-4 tabs PRN, max 15 tabs in

24hr

500mg BID

Antacid for relief of heartburn, calcium

supplement

Calcium supplement

Hypercalcemia, renal impairment

Hypercalcemia nephrolithiasis

Heartburn controlled,

calcium levels WNL

Heparin

anticoagulant

18 units/kg/h 14,000 units

subcutaneous q12 hours

Inactivates

thrombin and other clotting

factors

History of PE PTT, hemoglobin

levels

Bleeding

thrombocytopenia

No formation of

thrombus

Miralax (polyethylene

glycol 3350) Osmotic laxatives

1 capful daily PRN 17gm (1 capful) daily in the

morning

Causes water retention in stool

Prophylactic for pain medication

use

Hypersensitivity GI obstruction

Nausea cramping

Normal bowel movements

Lyrica

(pregabalin) Neurologic

75-300mg PO BID 50mg PO TID Binds to calcium

channels reducing neurotransmitter

release

Spinal cord injury Renal impairment

Alcohol use

Dizziness

Constipation

Neurologic pain

controlled

coumadin

(warfarin) Anticoagulant

2-5mg daily up to 10mg BID

7.5mg daily

Inhibits vitamin k

dependent

coagulation

Atrial fibrillation PT/INR (2-3) Bleeding risk

Ecchymosis nausea

INR WNL

Azactam

(Aztreonam in Dextrose)

Antibacterial

1-2g IV q 6-8 hours

2g in100ml q 6

hours given as

100ml/hr

Antibacterial,

inhibits cell wall

synthesis

osteomyelitis

Liver function

tests, Creatinine

levels

Phlebitis diarrhea

No

signs/symptoms

of infection

Vancomycin

(Vancocin) Glycopeptides

500-2000mg/day

divided q 6-8 hours

1750mg every

12 hours

Bactericidal,

inhibits cell wall and RNA synthesis

osteomyelitis

Renal impairment

Intestinal inflammation

Vomiting

Rigors

No

signs/symptoms of infection

Imdur

(Isosorbide Mononitrate)

Vasodialators

20mg PO BID 60mg daily Vascular smooth

muscle relaxation Hypertension

Caution with CHF

Hypotension (hold

if BP systolic less than 100mmHg)

Headache

Dizziness BP WNL

Synthroid

(levothyroxine) Thyroid

25-300mcg daily 60mcg daily Replaces thyroxine

(T4) hypothyroidism

T4 labs

Heart rate

Palpitations

tremor T4 levels WNL

Zestril (Lisinopril)

10-40mg daily 5mg daily

Lowers BP, inhibits

angiotensin

conversion

Hypertension

Hypotension (hold

if BP systolic less than 100mmHg)

BUN baseline

Dizziness Cough

BP WNL

Claritin (Loratadine)

antihistmine

10mg daily 10mg daily Relieves allergy

symptoms Allergies

Renal impairment Hypersensitivity

to medication

Abdominal pain Dry mucous

membranes

No signs/symptoms

of allergies

Lopressor (metoprolol

tartrate) Beta blockers

20-200mg BID 60mg BID Lowers HR Hypertension

A fib

HR (hold if rate less than 50bpm)

Heart failure

Dyspnea

Bradycardia HR and BP WNL

Protonix

(pantoprazole)

Proton pump inhibitors

20-40mg PO/NG 30 mins before

meal

40mg before

breakfast and dinner diluted

with 5-10ml saline

Reduces stomach acid

heartburn Magnesium

baseline

Nausea

Abdominal pain

Relief of

heartburn

Norco

(hydrocodone/ acetaminophen)

Opioid

5/325

7.5/325 10/326

Q 4-6hours PRN

10/325mg PRN 2 tabs

Blocks opioid

receptors, pain

control

Pain related to injury

Creatinine

baseline

Liver function

Constipation Drowsiness

Pain well managed

Nitrostat (nitroglycerin)

vasodilator

0.3-0.6mg SL q 5 min max of 3

doses , call 911

0.4mg SL PRN Vascular smooth

muscle relaxation Angina

BP

MI

Headache

hypotension

No symptoms of

angina

Zofran

(ondansetron)

Nausea/vomiting

4-5ml IV q 6 hours

IVP 4mg/2ml q 8 hours PRN

Relieves nausea

Antagonizes serotonin

receptors

Nausea and vomiting

Bradycardia

Hepatic

impairment

Constipation Headache

Nausea and

vomiting

managed

Ducolax (bisacodyl)

Stimulant laxatives

1-3 tabs daily

PRN 16mg daily

Relieves constipation,

increases peristalsis

Constipation GI obstruction

Rectal bleeding

Abdominal

cramping Vomiting

Regular bowel

movements

Insulin Type

Lantus (insulin glargine)

Onset 1 hour

Peak 5 hours Duration 24 hours

Individualize up

to 100 units 22 units bedtime

Stimulates glucose

uptake DM type 2

Blood glucose

level

Hypoglycemia

Weight gain

Blood glucose

levels WNL

Insulin Type

Humalog

(insulin lispro) Onset 0-15 mins

Peak 30-90 mins

Duration 6-8

hours

Individualize up

to 200 units

Before meals and bedtime sliding scale

BS <70- follow facility protocol

BS 151-200 1 unit BS 201-250 2 units BS 251-300 3 units BS 301- 350 4 units BS 351-400 5 units BS >400 Call Doctor

Stimulates

peripheral glucose uptake

DM type 2 Blood glucose

levels

Hypoglycemia

Rash

Blood glucose

levels WNL

Note: You may choose to use hand-written or pre-printed medication cards, but be sure to STUDY and KNOW their contents!

LAB VALUES SUMMARY

Medical Diagnosis Diagnosis #1 Diagnosis #2 Diagnosis #3

Diagnosis #4

List laboratory and diagnostic tests found in your text for admitting and secondary medical diagnoses.

Atrial Fibrillation Osteomyelitis Type 2 DM

Hypertension

Pt/INR Vancotrough CMP CBC

Troponin T CBC Glucose CMP

CBC CMP

ESR

CRP

Mg

ANALYSIS OF LAB VALUES

Test Normal Value Admitting date / value

Follow up date / value

Cause of abnormal finding

Implications for care

RBC

4.4-5.8 L 3.0 Anemia Monitor labs, food intake

Hemoglobin

13.8-17.3

L 8.6 Anemia Monitor labs, food intake

Hematocrit

41.0-52.0

L 27.0 Anemia Monitor labs, food intake

RDW-SD

36.4-46.3

H 46.5 Anemia Monitor labs, food intake

ESR

0-14

H 100 Infection Check osteomyelitis

Calcium

8.4-10.2 L 7.6 malnutrition Encourage food intake

Magnesium

1.8-2.4 L 1.6 malnutrition Encourage food intake

Gulcose

60-115 H 175 DM Monitor glucose levels

Bilirubin total

0.2-1.2 L <0.2 Liver disease Monitor liver function

AST

0-46 H 59 Liver disease Monitor liver function

ALT 6-40 H 74 Liver disease Monitor liver function

Total protein 6-8

L 4.6 Malnutrition Encourage food intake

Albumin

3.5-5 L 2.1 malnutrition Encourage food intake

CRP 0-0.7 H 1.9 inflammation Administer antibiotics

PT

9.3-11.3 H 17.0 Coumadin

therapy Monitor labs, skin integrity

INR 0.91-1.09 H 1.64 Coumadin therapy

Monitor labs, skin integrity

Troponin T Normal <0.04 Indeterminate >0.04<0.1 MI > 0.1

<0.01

WNL

Vanco Trough Therapeutic range Trough 5-15ug/ml Peak 20-40ug/ml

10.8ug/ml WNL

ANALYSIS OF LAB VALUES Day 2 List all other pertinent normal or abnormal lab values.

Test Normal Value Admitting date / value

Follow up date / value

Cause of Abnormal finding

Implications for care

PT 9.3-11.3 H 20.4 Coumadin therapy

Monitor labs, skin integrity

INR 0.91-1.09 H 1.96 Coumadin therapy

Monitor labs, skin integrity

RBC 4.4-5.8 L 2.89 Anemia Monitor labs, food intake

Hemoglobin 13.8-17.3

L 8.2 Anemia Monitor labs, food intake

Hematocrit 41.0-52.0

L 27.0 Anemia Monitor labs, food intake

MCHC 31.0-36.0 L 30.4 Anemia Monitor labs, food intake

RDW-CV 12.0-15.0 H 16.2 Anemia Monitor labs, food intake

RDW-SD 36.4-46.3 H 54.2 Anemia Monitor labs, food intake

Calcium 8.4-10.2 L 8.1 Malnutrition Encourage food intake

Albumin 3.5-5 L 2.5 Malnutrition Encourage food intake

Total Protein 6-8 L 5.1 Malnutrition Encourage food intake

Glucose 60-115 H 229 DM Monitor glucose levels

Bilirubin Total

0.2-1.2 L <0.2 Liver disease Monitor liver function

ALK Phosphate

26-126 H 131 Liver disease Monitor liver function

ALT 6-40 H 50 Liver disease Monitor liver function

Magnesium 1.8-2.4 L 1.7 Malnutrition Encourage food intake

ESR 0-14 H 90 Infection Monitor osteomyelitis

Student Name ________Amy Tillman_________________________________________ Date __3/31_________

Patient Age/Sex __Male_____ Medical Diagnosis ___Atrial Fibrillation_____ Code Status __Full____________

MENTAL STATUS

LOC and orientation X3 O x3, lethargic

Appearance Naked, disheveled

Cognition Appropriate

PAIN

Location, severity, quality, radiation, duration, precipitating/alleviating factors, associated symptoms

Chest and shoulder- right sided, 2/10 , deep and sharp, worse with

deep breaths

HEAD AND NECK

Hair and skin Shaved head, pale, dry, cool

Eyes: sclera, conjunctivae, pupil reactivity PERRLA, sclera off white, pink moist

Eyes: vision/aids Wears glasses

Ears: lesions, hearing/aids Lost hearing aids, hard of hearing, symmetric

Nose: symmetry, mucosa, drainage Symmetrical, no drainage

Mouth: mucosa, tongue, dentation, lesions Pink, moist, midline, has dentures

Swallowing/ Appetite No dysphagia, appetite good

Trachea position Midline

JVD at 45 degrees Negative

UPPER EXTREMITIES

Skin Right thumb absent, surgical scar right shoulder, intact, dry

Pulses (brachial, radial) +2 bilaterally

Capillary refill < 3 seconds

Strength/ROM Strong, equal bilaterally

Turgor/edema No edema, recoil

CHEST/BACK

Shape Symmetrical

Respiratory effort/SpO2 Non labored

Cough/sputum None

Lung sounds anterior and posterior Clear bilaterally with diminished sounds in lower lobes

Skin condition/integrity Surgical incision upper back and neck, well approximated, mild bruising

Heart sounds No extra sounds

Apical pulse rate/rhythm (auscultate full min) 70, regular rate and rhythm

ABDOMEN/PERINEAL AREA

Contour, symmetry Transverse surgical scar, distended, symmetrical

Bowel sounds in 4 quadrants Active

Tenderness Negative

Urinary pattern/color Foley in place, pale yellow, clear

Bowel pattern/character/last BM Regular daily, soft, 3/31 900

Perineum (if appropriate) n/a

LOWER EXTREMITIES

Skin color/integrity Scab on lateral left pinky toe, pale, cool, dry

Edema Negative

Pulses (femoral, popliteal, PT, DP) Dorsalis pedis +2 bilateral

Capillary refill < 3 seconds

Strength/ROM Flaccid, loss of sensation, paraplegia

EQUIPMENT

Pumps/ Tubes PICC line left arm, foley

DURING SHIFT

Vital signs/time BP: 131/68 Pulse: 70 Respiratory rate: 16

Temperature: 97.9 O2 Sat: 96% Pain: 2/10

Blood glucose monitoring results/insulin 700 - 167

Intake and output Adequate

Food intake/Appetite/Nausea Appetite good, denies nausea

IV solution and rate/hourly checks See attached medication list

Significant lab results See attached labs

Support system/SO involvement Daughter and grandson

Patient education completed Yes

NURSING DIAGNOSIS

Risk for decreased cardiac perfusion r/t atrial fibrillation aeb altered heart rhythm and EKG results.

SOAP NOTE (on above nursing diagnosis only)

S: States he experiences chest pain with deep breathing, rated as 2/10 on pain scale, describes as deep and sharp.

O: CV- Vital signs stable, apical pulse 70, rate and rhythm normal. No edema noted, homan’s sign negative. Peripheral

pulses +2 bilaterally, capillary refill < 3 seconds. RESP- Oxygen saturation 96%, room air, Lung sounds clear bilaterally

with diminished sounds in lower lobes. No accessory muscle use. GI- Bowel sounds active x 4, mild distention, regular

soft BM, denies N/V. GU- foley catheter in place, clear and pale yellow. MUSC- Lower extremity paraplegia, upper body

strong equal bilaterally. SKIN- pale, dry and cool. Surgical incision on neck and upper back midline. Pink area over coccyx.

NEUR- Oriented x 3, lethargic, CN intact.

A: Patient is progressing.

P: Continue with care plan.

END OF SHIFT CHECK-OUT

Patient safe and comfortable Meds administered Reported off to RN and instructor

I&O documented MAR signed Student signature ______________________________

DAY TWO PREPARATION

EVALUATION

Did you choose the appropriate nursing diagnosis for Day One? □Yes □No

What would have been a better choice?

Were your objectives and interventions appropriate? □Yes □No

What would have been more appropriate?

Nursing Care Plan for SECOND PRIORITY Nursing Diagnosis

Nursing Diagnosis in PES Format Patient Expected Outcome (measurable and with time frame)

Individualized & Prioritized Nursing Interventions with Referenced Evidence/Rationale

P Impaired physical mobility Meet mutually defined goals of increased ambulation and exercise that include individual choice, preference and enjoyment in the exercise prescription by discharge.

1. Assess: Monitor and record client’s ability to tolerate activity and use all four extremities; note pulse rate, blood

pressure, dyspnea, and skin color before and after activity. Refer to the care plan for activity intolerance. Rationale: Use

valid and reliable screening procedures and tools to assess the

client’s preparticipation in exercise health screening and risk stratification for exercise testing (low, moderate, or high risk).

(Ackley, Ladwig pg.538)

E r/t loss of sensation to lower extremities

2. Intervene: Before activity, observe for and, if possible,

treat pain with massage, heat pack to affected area, or

medication. Ensure that client is not over sedated. Rationale: Pain limits mobility and is often exacerbated by movement.

(Ackley, Ladwig pg. 538)

S aeb paraplegia, muscle atrophy AEB: Patient demonstrating exercise preference with increased ambulation

3. Teaching: Increase independence in ADLs, encouraging

self-efficacy and discouraging helplessness as the client gets

stronger. Rationale: Providing unnecessary assistance with transfers and bathing activities may promote dependence and

a loss of mobility. A function-focused care intervention (designed to optimize physical activity and function with

Parkinson’s disease clients) demonstrated a significant effect

on increasing outcome expectations for exercise, improving

functional performance and increasing time spent in exercise and physical activity. (Ackley, Ladwig pg 539)

Defining Characteristics (from book – did you pick the correct diagnosis?) Decreased reaction time; difficulty turning; engages in substitutions for movement (e.g. increased attention to other’s activity, controlling behavior, focus on pre-illness disability/activity); exertional dyspnea; gait changes; jerky movements; limited ability to perform gross motor skills; limited ability to perform fine motor skills; limited range of motion; movement-induced tremor; postural instability; slowed movement; uncoordinated movements. (Ackley, Ladwig pg.536)

4. Discharge: Refer to home health aide services to support the client and family through changing levels of mobility. Reinforce need to promote independence in mobility as tolerated. Rationale: Providing unnecessary assistance with transfers, bathing, and dressing activities may promote dependence and a loss of mobility rather than optimizing a person’s underlying physical capability. Such attentive care may actually prevent older adults from using their remaining abilities. (Ackley, Ladwig pg. 541)

Student Name ________Amy Tillman____________________________ Date ___4/1_______

Patient Age/Sex _ male___ Medical Diagnosis ___Atrial Fibrillation_________ Code Status _____Full______

MENTAL STATUS

LOC and orientation X3 O x3, tires easily

Appearance Naked, disheveled

Cognition Appropriate

PAIN

Location, severity, quality, radiation, duration, precipitating/alleviating factors, associated symptoms

Chest, 5/10, burning epigastric area, coughing makes it worse

HEAD AND NECK

Hair and skin Pale, warm, dry, facial hair

Eyes: sclerae, conjunctivae, pupil reactivity Moist, slightly red, PERRLA

Eyes: vision/aids Wears glasses

Ears: lesions, hearing/aids HOH, lost hearing aids

Nose: symmetry, mucosa, drainage Symmetric, no drainage

Mouth: mucosa, tongue, dentation, lesions Pink moist, dentures out, no lesions

Swallowing/ Appetite No dysphagia, appetite “good”

Trachea position Midline

JVD at 45 degrees Negative

UPPER EXTREMITIES

Skin Cool pale dry

Pulses (brachial, radial) +2 bilateral

Capillary refill < 3 seconds bilateral

Strength/ROM Strong equal bilateral

Turgor/edema No edema, recoil

CHEST/BACK

Shape Symmetric

Respiratory effort/SpO2 Nonlabored 02 96% RA

Cough/sputum None

Lung sounds anterior and posterior Clear bilateral, diminished lower lobes

Skin condition/integrity Surgical incision well approximated, intact

Heart sounds No extra sounds

Apical pulse rate/rhythm (auscultate full min) 86, regular rate and rhythm

ABDOMEN/PERINEAL AREA

Contour, symmetry Distended, firm

Bowel sounds in 4 quadrants Active

Tenderness None- feels full

Urinary pattern/color Foley, clear pale yellow

Bowel pattern/character/last BM Regular, soft 600

Perineum (if appropriate) n/a

LOWER EXTREMITIES

Skin color/integrity Pale, cool, dry

Edema None

Pulses (femoral, popliteal, PT, DP) Right DP +1, left unable to feel cap refill checked

Capillary refill < 3 bilateral

Strength/ROM Flaccid, muscle atropy

EQUIPMENT

Pumps/ tubes PICC left arm, foley

DURING SHIFT

Vital signs/time 700- BP:145/81 Pulse: 86 RR: 16 Temp: 98.6

O2 Sat: 96% Pain: 5/10

Blood glucose monitoring results/insulin 730- glucose 227, given 9 units plus 2 units sliding scale

Intake and output Adequate

Food intake/Appetite/Nausea 100% of meals

IV solution and rate/hourly checks See attached medication list

Significant lab results See attached labs

Support system/SO involvement Daughter and grandson

Patient education completed yes

NURSING DIAGNOSIS

Risk for decreased cardiac perfusion r/t atrial fibrillation aeb altered heart rhythm and EKG results.

SOAP NOTE (on above nursing diagnosis only)

S: States “how am I going to get back on my feet and do my own thing?”

O: CV- Systolic BP elevated, apical pulse 86, rate and rhythm normal. No edema noted. Brachial and radial pulses +2

bilaterally, Right dorsalis pedis +1, unable to palpate left, capillary refill < 3 seconds. RESP- Oxygen saturation 96%, room

air, Lung sounds clear bilaterally with diminished sounds in lower lobes. No accessory muscle use. GI- Bowel sounds

active x 4, distended and firm, regular soft BM, denies N/V. GU- foley catheter, clear and pale yellow. MUSC- Lower

extremity paraplegia with muscle atrophy, upper body strong equal bilaterally. SKIN- pale, dry warm upper body and

cool lower extremities. Surgical incision on neck and upper back midline. NEUR- Oriented x 3, tired easily, CN intact.

A: Patient struggling with current condition.

P: Continue with care plan.

END OF SHIFT CHECK-OUT

Patient safe and comfortable Meds administered Reported off to RN and instructor

I&O documented MAR signed Student signature ______________________________