CSU, STANISLAUS B.S.N.CLINICAL PLAN OF CARE

Student: Vanessa Van Steyn Date of Care: 1/6/14-1/7/14 Room Number: 428

Patient DataAdmitting Diagnosis Complaint Chest Pain, STEMI Age 63

Spiritual Focus Jehovah’s Witness- NO BLOOD TRANSF. Culture Hispanic

Patient Initials ** Gender M

Height 167 inches Weight 78 kg

Admitting Date 1/1/14

Vital SignsBP taken q15min while on Dobutamine and Nitroglycerin drip. Dobutamine D/C at 2000 on 1/6/14; Nitroglycerin D/C at 2300 1/6/14. All other vital signs to be taken q4h.

T P R B/P O2Sat Pain Scale97.2

97.8

98.0

98.2

85 82 86 81 16 20 18 26 See Below 94 94 95 98 0 0 6 8

BP: Time Taken 1/6/14 1/7/14 BP: Time Taken 1/6/14 1/7/141430 112/68 1745 104/641445 99/63 1800 100/671500 104/65 1815 100/641515 Walking 1830 108/651530 99/59 1845 89/621545 97/60 1900 95/581600 101/64 103/63 1915 96/551615 98/61 1930 92/491630 99/59 1945 97/571645 95/55 2000 105/62 99/541700 109/69 2015 91/541715 104/64 2030 102/54

1730 99/62 2045 Walking

Past Medical HistoryType II Diabetes, Hypertension, Hyperlipidemia, Unstable Angina type II, CHF III, Acute Left Vent. Systolic Dysfunction.

Surgical HistoryLeft Knee Surgery (unknown reason)

Diet: Clear Liquid (1/5/14)NPO (1/6/14)Clear Liquid (1/7/14)

Activity: Ambulate in the hallwayAnkle Pumps x 20Wrist Pumps x 20

Foley: Yes NG/Feeding Tube: NG inserted 1/5/14 with intermittent suctionD/C 1/6/14

Drains/Tubes:

Mediastinal Chest tube X 2

Advance Directives:

No Code Status: Full GlucoseMonitoring:

AC and qhs

VS Freq: BP q15m with Dobutamine and nitroglycerin drip.q4h all other

TEDs/SCDs: TEDS

PCA/Epidural: None Telemetry: Yes

Vascular Access: IV Site: Triple Lumen Catheter Central Line IV Solution:

0.9% NS @ 5ml/hr.

Safety Considerations: Pt. is unwilling to receive blood transfusions due to religious beliefs. States he is willing to accept synthetic clotting factors and albumin. Use pediatric tubes when obtaining blood draws… no CBC or blood levels.

Dressing Changes: Mediastinal chest site, 4 dressings for staples on left leg (donor site)

Labs to be Drawn: BMP, Magnesium (AM 1/6 and 1/7)

Scheduled Procedures: None

Notes on Pathophysiology: Pt arrives at ER with complaints of chest pain ECG shows STEMICardiac Cath procedure Triple Vessel Disease (decided nothing much they could do in cath lab, and inserted balloon pump to hold pt. over until emergency surgery) Emergency CABG procedure with 4 donor vessels paralytic ileus NPO

Lab and Diagnostic Test DataTest type

(date)Normal Range

Pt Results Trends ↑ Rationale(Specific to pt.)

Nursing implications related to patient care & teaching

Chem-7 1/5 1/6 1/7 Patient’s electrolytes are within normal limits. His glucose level is slightly high however this could be due to his type 2 diabetes and stress. This blood glucose will be managed with his prescribed insulin and continue to be monitored throughout his stay. The magnesium can be increased due to dehydration, and I was also thinking it could be raised due to acute kidney failure due to decreased blood flow from the STEMI

I would expect the physician to continue to monitor the magnesium level due to it trending high and him having a history of alcoholism. I would also expect the nurses and physicians to monitor the glucose, often by use of a finger stick, in order to make sure he does not fall into hyper or hypoglycemia. The rest of his electrolytes look great, but because he switches between NPO and clear liquid diet I would expect them to monitor electrolytes to see if they need to add any electrolytes to his solution to keep his heart beating normally.

Na 135-145 136 133 135K 3.3-5.0 4.1 4.2 4.0Cl 95-110 109 105 105CO 2 24-32 24 25 25Calcium 8.0-11.0 8.1 7.9 7.5Glucose 70-110 87 136 135 HighMagnesium 1.2-2.0 2.6 2.5 2.8 High

Kidneys 1/5 1/6 1/7 The BUN level can be raised in patients experiencing acute STEMI’s as the kidneys have experienced a decrease in blood flow.The creatinine and GFR levels however indicate that the kidneys are functioning properly, with no disease present.

I would expect the doctor to continue to monitor the BUN levels during the patient’s hospital stay. Although it is the only kidney lab that is elevated and is probably due the STEMI, I believe the physician would continue to make sure that the BUN returned back to normal limits. During this period I would expect the doctor to use caution when ordering renal toxic medications such as NSAIDS and ACE inhibitors.

BUN 8-22 15 26 27 HighCreatinine 0.5-1.3 0.8

01.01

0.91

GFR >60 >60 >60 >60

Liver 1/6 1/7 The pt’s liver labs are all within normal limits besides the AST, protein and the albumin. Albumin and protein are probably decreased because this patient is on an NPO/Clear liquid diet and therefore is not taking in any protein. The AST is

I would be sure to try to increase the patient’s diet to a level where the patient was consuming more protein, thus increasing albumin level. I would also expect the staff to continue to monitor the AST and hope to see that it continues to remain within defined limits and that no

Total Protein 6.0-9.0 5.8 5.5 LowAlbumin 3.8-5.1 3.1 2.7 LowGlobulin 2.1-3.7 2.7 2.8Bilirubin Total 0.3-1.3 0.9 1.1AST 8-42 62 38 HighALT 10-60 34 29

Test type(date)

Normal Range

Pt Results Trends ↑ Rationale(Specific to pt.)

Nursing implications related to patient care & teaching

increased because when disease or injury affects cells throughout the body. In this case, the AST is measuring cells in the heart, and skeletal muscle, which both suffered trauma during the STEMI and surgery.

further damage seems to be occurring.Lipase 10-140 44 ---

Cardiac Troponin levels above 0.50 are highly suggestive of acute myocardial infarction and is considered a medical emergency. Staff must follow the ASA and Beta-Blocker protocols with a troponin level >0.50.

Patient needed to be taken to the cardiac cath lab ASAP. Emergency CABG surgery was performed.After, rest and monitoring of vital signs are extremely important. I would continue to monitor troponin levels and hopefully watch them decline back to normal levels.

Troponin I 0.01-0.06 0.77 HighFibrinogen 155-558 167

Blood 1/5/14 This patient recently went through cardiac surgery but received no blood replacement therefore we expect to see an overall decrease of all blood products. This is why we see a decrease in Hgb, Hct, and RBC. We

The patient is prescribed ferrous sulfate, thiamine, and folic acid. Although these medications will definitely help this patient’s RBC levels increase, he has not been taking them because he is NPO. When he begins taking them we expect to

WBC 4.5-11.0 18.2 HighHgb 13-16 9.9 LowHct 37-49 29.5 LowRBC 4.5-5.3 3.22 LowPlatelets 130-400 114 LowCoagulation 1/2/14 Although this patient’s INR and PT

are slightly increased, this is because he is on an aspirin and Plavix anticoagulation therapy. In order to be sure that this patient will not experience another STEMI, he will need to continue on anticoagulation therapy.

I imagine the patient would continue to receive anticoagulant therapy such as low dose aspirin or Plavix when discharged home.I would also teach the patient to use a soft bristle tooth brush, avoid using a razor to shave his face, and be aware of signs of internal bleeds such as black tarry stool.

INR 2.0-3.0 (for MI)

1.5

PT 9.5-12.2 17.2 HighPTT 25-36 33

X-RAY (cardiac cath) w/ contrast

Severe distal left main disease.

Subtotal occlusion of right coronary artery

Total occlusion of circumflex artery

The x-ray was used during the cardiac catheterization procedure to find out which vessels were blocked. It turned out that multiple vessels were blocked and therefore they were unable to stent any vessels to correct the problem. The doctor then decided to add a balloon pump into the heart in order to allow the heart to rest while awaiting the emergency CABG procedure.

Test type(date)

Normal Range

Pt Results Trends ↑ Rationale(Specific to pt.)

Nursing implications related to patient care & teaching

“Multi-vessel Disease”

EKG Normal Sinus Rhythm

Sinus Rhythm with acute elevated ST segment: STEMI

The EKG that was done upon entrance to the ER showed that the patient had an elevated ST segment. This made his situation an emergency, and he was rushed to the Cardiac Cath lab.

Medication Allergies: NKDA

MedicationsGeneric & Trade Name Drug Classification(Therapeutic &Pharmacologic)

Dose/Route Frequency

Action of drug and Rationale(specific to Pt)

Significant Side Effects Nursing implications related to patient care & teaching

PantoprazoleProtonixProton Pump Inhibitor

40mg PO daily (hold if NPO)

40mg IV(if NPO; dilute w/10ml NS over 2 min)

Binds to an enzyme in presence of acidic pH preventing transport of H ions further into the lumenLessens acid reflux

Hyperglycemia, hypomagnesaemia, abdominal pain, headache, diarrhea, flatulence.

Avoid alcohol, Avoid NSAIDS, and any foods causing GI irritation.Report any black/tarry stools.Tell prescriber if pregnant or breastfeeding.

MupirocinBactrobanAntibacterial

1 tube BID for 5 days- Nasal(1/2/14-1/6/14)

Bactericidal, inhibits protein synthesis in susceptible bacteria.

Headache, nausea, burning, stinging, pain, pruritus, rash, swelling, tenderness.

Do not use in burn patients, do not get in eyes.

ClopridogrelPlavixAnti-platelet agent

1 Tab daily POWith meals.Hold if Plt <70,000(hold if NPO)

Inhibits platelet aggregation by inhibiting ADP.

Upper resp tract infection, chest pain, headache, flu like symptoms, pain, dizziness, diarrhea, rash, rhinitis, depression

Warn patient about risks of bleeding and what to watch for when on an anti-platelet, including bleeding from mucosa, excessive bleeding, or uncontrolled bleeding.Teach patient to use a soft toothbrush and an electric razor to minimize risk of blood loss.

MetoprololLopressor

50 mg daily PO25 mg daily PO

Blocks response to the beta adrenergic

Orthostatic hypertension, drowsiness, dizziness,

Monitor BP and HR. Do not crush or chew. Watch for orthostatic

Beta Blocker Hold if SBP<110(hold if NPO)

stimulation. Selective for B1 receptors no effect on B2. Lowers BP.

headache, diarrhea, bradycardia, pruritus, heart failure, hypotension

hypotension when standing. Teach patient to rise slowly from rest, and warn of effects of dizziness and tiredness with this medication. Medication may mask the signs of hypoglycemia; make sure to test blood sugar often.

Docusate SodiumColaceLaxative

100 mg PO dailyHold for diarrhea(hold if NPO)

Promotes incorporation of water into stool, increases fecal mass.Softens stool.

Electrolyte imbalanceDehydrationAbdominal cramps, nausea, vomiting, diarrhea, rashes, urine discoloration.

Long-term use may cause dependence.Drink plenty of water with use of laxatives.

AspirinBaby AspirinAntiplatelet agent

81 mg PO daily with meal.(hold if NPO)

Inhibits prostaglandin synthesis. Inhibits platelet aggregation, with antipyretic and analgesic activity. Decreases clot formation in blood stream.

Angioedema, bronchospasm, GI pain & bleeds, Hepatotoxicity, hearing loss, bleeding, Pulmonary edema

Warn patient about risks of bleeding and what to watch for when on an anti-coagulant, including bleeding from mucosa, excessive bleeding, or uncontrolled bleeding.Teach patient to use a soft toothbrush and an electric razor to minimize risk of blood loss.

Magnesium OxideMag-Ox 400Antacid

400 mg PO BIDHold if Mag >3(hold if NPO)

Mineral, when combined with water which acts as an antacid, counteracting stomach acid with its alkaline properties.

DiarrheaGI irritation

Keep serum magnesium between 1.5-2.5.May have a laxative effectCaution with renal impairment increasing absorption/ decreasing excretion time.Warn patient not to take supplement on an empty stomach.

FurosemideLasixDiuretics

20 mg IV BID Loop diuretic that inhibits reabsorption of Na and Cl ions causing increases in water, calcium, magnesium, sodium and cl.

Hyperuricemia, hypokalemia, anemia, diarrhea, glycosuria, headache, hypocalcemia, hypomagnesemia, hypotension, ototoxicity.

May lead to excessive electrolyte and water depletion, use caution.Use caution with Diabetes, SLE, liver disease, renal impairment.

KClK-dur

20 mEq BID PO with meals

Used to replace serum potassium and prevent

Ab pain, diarrhea, flatulence, nausea,

Assess for S&S of hypo and hyperkalemia.

Electrolyte replacement Hold if K> 4.7(hold if NPO)

hypokalemia especially with use of a diuretic.

vomiting, arrhythmia Monitor pulse, ECG, BP throughout therapyMix with juice or other fluids to decrease unpleasant taste.

ThiamineVitamin B1B Vitamins

100 mg daily PO(hold if NPO)

Needed for carbohydrate and pyruvate metabolism. Functions as a vitamin.

Collapse, pulmonary edema, nausea, diarrhea, angioneurotic edema, anaphylaxis.

Look for absence of nausea and vomiting, anorexia, insomnia, muscle weakness.Teach about including vitamin B rich foods in diet such as seeds, nuts, fish and enriched grains.

Folic AcidFolviteVitamin

2 mg daily PO(hold if NPO)

Needed for erythropoietin synthesis and to increase levels of RBC, WBC, and platelets. Helps fight anemia. Especially important in this pt. to hopefully make it so he will not become too anemic without a blood transfusion.

Bronchospasm, flushing Monitor signs and symptoms of anemia, and expect to see an increase in energy level, a decrease in sensitivity to cold and other anemic signs.Teach about eating foods high in folic acid such as beans, legumes and dark leafy green vegetables.Explain to the patient that by taking his folic acid vitamin and eating folic acid rich foods, he may be able to keep his blood counts high enough to not require a transfusion.Explain to the patient that these vitamins are not a blood product (just in case!)

Ferrous SulfateFeratabIron Products

325 mg BID PO with meals(hold if NPO)

Replaces iron stores needed for proper RBC development in order to treat iron deficiency anemia.

Nausea, constipation, epigastric pain, black/red tarry stool, vomiting and diarrhea, discolored teeth & eyes.

Watch for signs and symptoms of toxicity such as nausea and vomiting, diarrhea, hematemesis, pallor, cyanosis, shock, coma.Teach patient that the iron supplement may make his stool dark or red, and to not be concerned.Also explain to the patient that he may experience staining of his teeth so try to take the supplement (if

liquid) through a straw.Teach patient that he can take the vitamin with food if it upsets his stomach.

AtorvastatinLipitorStatin

10 mg qhs PO(hold if NPO)

HMG-CoA reductase inhibitor. Inhibits synthesis of cholesterol due to competitive inhibition.

Headache, chest pain, peripheral edema, sinusitis, diarrhea, weakness, rash, back pain

Increased blood sugar and increased HBA1c may occur. Monitor with FSBS and cover with insulin Humalog.Risk of rhabdomyolysisRisk of myopathy

LisinoprilPrinivilACE inhibitor

10 mg daily POHold if SBP<110(hold if NPO)

Prevents conversion of angiotensin1 to angiotensin 2 through inhibition of angiotensin converting enzyme. Decreases BP through vasoconstriction, increased renin activity and decreased aldosterone production.

Dizziness, cough, headache, hyperkalemia, diarrhea, hypotension, chest pain, fatigue, nausea and vomiting, rash

Monitor BP and HR. Watch for orthostatic hypotension when standing. Teach patient to rise slowly from rest, and warn of effects of dizziness and tiredness with this medication.

Insulin AspartNovoLogInsulins

Dose Sched: AC& qhsFSBS Dose70-130 0 units131-180 4 units181-240 8 units241-300 10 units301-350 12 units351-400 16 units>400 16 units

CALL MD!!

DiabetesBlood Sugar Control

Hypoglycemia, allergic reactions including anaphylaxis, erythema, pruritus, swelling.

Assess for symptoms of hypoglycemia including: anxiety, restlessness, tingling in hands and feet, chills, cold sweats, confusion, cool, pale, skin, difficulty in concentration, Drowsiness, nightmares, trouble sleeping, excessive hunger, headache, nervousness.Overdose is manifested by signs of hypoglycemia. Teach pt. to become aware of hypoglycemia reactions.

AmlodipineNorvascCalcium Channel Blockers

5 mg PO @1800 daily.Hold if SBP <110(hold if NPO)

Inhibits calcium ions from travelling across membranes of myocardial cells

Edema, headache, fatigue, palpitations, dizziness, nausea, flushing, abd pain, somnolence

May worsen angina and acute myocardial infarction. Monitor pain levels and give nitroglycerin as needed. Edema may develop.

inhibiting cardiac and vascular smooth muscle.

OndansetronZofranAntiemetic

PRN: N&V4mg IV q6h

Blocks effects of serotonin at sites located throughout the vagal nerve terminals decreasing nausea.

Headache, Malaise, Diarrhea, Dizziness, Constipation, Torsades de Pointes.

Assess for nausea, vomiting, abdominal distention, and bowel sounds before and after drug is given.

MetoclopramideReglanAntiemetic

PRN: N&V (if Zofran doesn’t work)q4h IV

Blocks dopamine receptors in the chemoreceptor trigger zone of CNS and sensitizes tissue to Ach, increasing upper GI motility and lower sphincter tone.

EPS,Fatigue, restlessness, sedation, diarrhea, nausea, galactorrhea, gynecomastia

Watch for S&S of extrapyramidal rxn including tardive dyskinesia. Do not administer for longer than 12 weeks.

Hydrocodone/APAPNorcoOpioid Analgesic

PRN: pain 6-85/325mg PO q4h(Do not give if NPO)

Binds opiate receptors in the CNS, produces generalized cns depression.

Confusion, dizziness, sedation, hypotension, constipation, dyspepsia, nausea, tolerance, dependence, dry mouth, respiratory depression

Administration on a regular basis often decreases pain a lot more than PRN.Assess RR regularlyGive medication before pain becomes severe.Assess pain on a pain scale of 1-10.No more than 3grams daily of acetaminophen may be taken due to liver failure.Turn and move slowly to decrease risk for orthostatic hypotension.Sugarless gum and candy reduce risk of dry mouth.

MorphineMorphineOpioid Analgesic

PRN: pain 7-102mg IV q4h

Binds to opiate receptors in the CNS

Confusion, sedation, hypotension, constipation, Respiratory depression,

Be aware of respiratory depression with too many CNS depressants given to patient.

DobutamineDobutrexInotropics

PRN: To wean CI over 2.3.250mg/250ml D5WConc: 1mg/mlRate: 1-2 mcg/kg/min

Stimulates beta adrenergic receptors with minor effects on HR or periphery.

Hypertension, increased HR, PVC, SOB, headache, nausea and vomiting, angina

Monitor BP and HR, ECG, PCWP, CO, CVP, and urinary output.Palpate peripheral pulses and notify physician if pulse deteriorates or

q10 minMax: 10mcg/kg/min

1-6-14 (new order): 1mg STAT, off in 12 hr (2000)

Increases CO without increasing HR.

extremities become cold and clammy.

Nitroglycerin PRN: to maintain post op parameters SBP > 95 & MAP 70-75.50mg/250ml D5WConc: 0.2 mg/mlRate: 5mcg/min q2-5 min IV

Causes systemic vasodilation which decreases the preload and myocardial 02 demand, decreasing angina pain.

Headache, hypotension, tachycardia, dizziness, methemoglobinemia, syncope, increase bleeding time, unstable angina, rebound hypertension, thrombocytopenia.

Monitor BP and HR. Watch for orthostatic hypotension when standing. Teach patient to rise slowly from rest, and warn of effects of dizziness and tiredness with this medication.

Hydralazine PRN: SBP>140 orMAP> 75Hold if SBP<100

10mg IV q4h

Vasodilates SM by direct relaxation, decreases BP (for HTN) with an increase in HR, SV, and CO.

Headache, tremor, dizziness, anxiety, palpitations, reflex tachycardia, angina, nausea and vomiting, anorexia, diarrhea and shock, leukopenia, agranulocytosis, thrombocytopenia.

Monitor BP, JVD, and pulse.Monitor electrolyte studies, and glucose studies and this medication may cause hyperglycemia. Assess for lupus like symptoms.Monitor daily weights and I&O, edema and lung sounds.Monitor orientation.Beware of signs of impending infection. Use proper hand washing.

1.) Diagnosis: Acute pain and discomfort RT CABG surgery AEB verbal pain rating of 8/10. Data to Support:CABG surgeryRestlessnessMediastinal wound with 2 chest tubes.3 incisions on left donor leg, closed with staples.Pt states acceptable pain at 4.Pain score 6/10, 8/10 when awake.Pain Medications Administered

Hydrocodone/APAPMorphine

Pt. splinting area when coughing

3.) Diagnosis: Risk for ineffective tissue perfusion RT anemia with refusal of blood products.Data to Support:RBC: 3.22Hct: 29.5Hgb: 9.9Prescribed:

Ferrous SulfateFolic AcidThiamine (B-12)

Refusal of blood products: due to religious beliefs- Jehovah’s Witness1800 ml sero-sanguineous drainage 1/6-1/7FatigueHx of alcohol abuse

Pt states drinking 6-7 beers daily

2.) Diagnosis: Risk for infection RT impaired skin integrity at mediastinal wound and left donor leg incisions.Data to Support:Mediastinal incision, left donor leg incisionsWounds clean & dryWBC: 18.2NPO/Clear Liquid DietAlbumin: 3.1; 2.7Type 2 diabetesBlood Sugar: 165,130,1431800 ml sero-sanguineous drainage (1/6-1/7)Urinary CatheterLengthy hospital stay

Expected Outcome/Goals:Pt. will not show any signs and symptoms of infection during hospital stay (fever, redness or

1.) Diagnosis: Acute pain and discomfort RT CABG surgery AEB verbal pain rating of 8/10. Data to Support:CABG surgeryRestlessnessMediastinal wound with 2 chest tubes.3 incisions on left donor leg, closed with staples.Pt states acceptable pain at 4.Pain score 6/10, 8/10 when awake.Pain Medications Administered

Hydrocodone/APAPMorphine

Pt. splinting area when coughing

5.) Knowledge: Patient will be able to show me how to properly use an incentive

spirometer. Patient will be able to tell me one food containing each of the

following vitamins: Iron, Folic Acid and vitamin B12. Patient will be able to show me how to do ankle and wrist

pumps given to him by OT. Patient will explain the importance of Plavix and aspirin & will

be able to describe the signs and symptoms of an internal bleed.

3.) Diagnosis: Risk for ineffective tissue perfusion RT anemia with refusal of blood products.Data to Support:RBC: 3.22Hct: 29.5Hgb: 9.9Prescribed:

Ferrous SulfateFolic AcidThiamine (B-12)

Refusal of blood products: due to religious beliefs- Jehovah’s Witness1800 ml sero-sanguineous drainage 1/6-1/7FatigueHx of alcohol abuse

Pt states drinking 6-7 beers daily

4.) Discharge Patient’s pain will be managed at a level <4 with use of

Norco. Patient’s labs will return back to within defined limits. Patient will not be experiencing any signs or symptoms

of infection. Patient will be gradually increased back to a regular

diet before discharge. Patient will be able to get up and out of bed without

complete assistance before discharge

2.) Diagnosis: Risk for infection RT impaired skin integrity at mediastinal wound and left donor leg incisions.Data to Support:Mediastinal incision, left donor leg incisionsWounds clean & dryWBC: 18.2NPO/Clear Liquid DietAlbumin: 3.1; 2.7Type 2 diabetesBlood Sugar: 165,130,1431800 ml sero-sanguineous drainage (1/6-1/7)Urinary CatheterLengthy hospital stay

Expected Outcome/Goals:Pt. will not show any signs and symptoms of infection during hospital stay (fever, redness or

Admitting Diagnosis: STEMIPriority Assessments: BP, O2 sat, CBC, Pain, Blood sugar, wound assessment, I&O

Evaluate Effects of Nursing Actions – Patient Response/OutcomesChief Medical Diagnosis: STEMIPriority Assessments: BP, O2 sat, CBC, Pain, Blood sugar, wound assessment, I&O

1. Nursing Care: Acute pain and discomfort RT CABG surgery AEB verbal pain rating of 8/10.Nursing Actions:Initial Assessment: checked vital signs and pain level.

Rotated patient to left side.

Check on patient, ask pain level.

Got patient up to walk.

Reassess vital signs

Initial assessment (day 2)

Patient given 5/325mg of Norco

Reassessed pain level 30 minutes later.

Got patient up to walk.

Check on patient

Patient Response and Outcome:

Vital Signs: T:97.2, P:85, R:16, O2:94, BP: 112/68. Patient states he is in no pain, states he is still very tired.

Patient tolerated procedure and went back to sleep.

Patient requests warm blanket. States pain at a zero

Patient requires a lot of assistance to walk, including 3 nurses. Gets very exhausted going down the hall in the hospital and requests to go back to sleep.

Vitals: T:97.8, P: 82, R:20, O2: 94, BP: 105/62. Patient states pain still at a 0/10.

Vital Signs: T: 98, P: 86, R:18, O2: 95, BP: 103/63 Pain: 6/10.

Patient tolerated medication administration, and continued watching TV.

Patient states pain 3/10. States feeling very tired. Allowed patient to rest until right before dinner.

Patient able to walk much further than the previous day. Also seems to need much less help than previously. Patient returned to chair.

Patient asleep.2. Nursing Care: Risk for infection RT impaired skin integrity at mediastinal wound and left donor leg incisions.Nursing Actions:Performed proper hand hygiene

Initial Assessment

Patient Response and Outcome:

Wound was clean, dry with edges well approximated. No dehiscence noted. No signs or symptoms of infection were present including warmth or redness in the area, no drainage in the left donor site. Two mediastinal chest tubes exiting the mediastinum were draining sero-sanguineous fluid, which was expected at this time.

Provide Foley Catheter Care

Reviewed patient’s labs

Checked pt’s blood sugar

Covered patient’s blood sugar with 4 units insulin

Changed dressing

Vital Signs: T:97.2, P:85, R:16, O2:94, BP: 112/68. Patient’s vitals show no signs or symptoms of infection at this time.

Provided catheter care to the patient in order to maintain cleanliness of Foley site. Patient tolerated procedure well.

WBC levels elevated possibly showing that patient is fighting an infection. Will continue to monitor for signs and symptoms of infection. Albumin level also low showing evidence for delayed wound healing. Will continue to monitor surgical sites for signs of delayed wound healing.

Blood sugar: 165.

Patient tolerated medication administration, no adverse events noted.

Dressing was soiled so nurse changed 3 dressings on left donor site before bed. Practiced great hand hygiene before and after dressing change and used sterile technique.

3. Nursing Care: Risk for ineffective tissue perfusion RT anemia with refusal of blood products.Nursing Actions:Initial Assessment:

Lower lights and provide relaxing atmosphere for rest. Ask visitors not to disturb patient while resting.

Check on patient.

Measured output from chest tube

Go for a walk

Reassess patient

Patient Response and Outcome:

T:97.2, P:85, R:16, O2:94, BP: 112/68. Patient is stating he is very tired. Perfusion looks good right now, however the patient’s fatigue could be due to low hgb & RBC.

Patient asleep.

Patient requesting a warm blanket. Brought patient a warm blanket and turned patient to the left side.

Chest tube drained approximately 1000 ml of sero-sanguineous blood on 1/6/14, and 800ml on 1/7/14.

Patient required a lot of rousing to wake him. Needed a lot of assistance to get out of bed, and followed patient with a chair in case he got too tired. Brought patient back to bed to rest.

Vitals: T: 97.8, P: 82, R:20, O2: 94, BP: 105/62. Patient still seems to be very lethargic.

Student Clinical Self-AppraisalWeekly (turn in with Care Plan/Map)

Student Vanessa Van Steyn Course Nurs 4810 Instructor Jo Sokolo

Instructions: Please evaluate your performance during clinical today using the following concepts:Patient Advocate Professional Demeanor FlexibleCritical Thinking Communication/rapport Peer SupportSelf-Initiated Team Player Skill AcquisitionSafety Organized EducatorLeadership Well-prepared DependableNursing Process Knowledgeable

Areas of Strength Today (1/6/14-1/7/14)

FlexibleOnce my day nurse’s shift was over, I got a new nurse whose main responsibility was preparing the newly deceased patient for the morgue. I felt that I was up for the challenge and glad I was flexible enough to take up the new task.

Skill AcquisitionI prepped the newly deceased patient, inserted a foley basically by myself, and worked a lot with cardiac drips and cardiac measurements. Overall, it was a good week!

Areas Needing Growth-Include plan of improvement

Professional DemeanorI felt that the code blue was a little unprofessional as the staff was not very sensitive to the patient’s family when discussing the patient’s status. I also felt that the staff was a little too jokey when prepping the body, but it could have been a coping mechanism. Next time, I will definitely try to maintain the respect I feel the patient deserved.

SafetyI wasn’t fitted with a mask specially used for H1N1, and didn’t realize how close I was standing next to the door during the code. Also, I feel that because I was working with two HIV+ patients this week, I should have been a lot more observant about what I was doing, although no adverse events occurred. Next time I will discuss safety with my nurse more clearly.

Instructor Comments: