California State University, Stanislaus

School of Nursing
N4810 Adult Health Nursing II Clinical
3 units
DIRECTIONS FOR COMPLETING THE CLINICAL PLAN OF CARE
The Clinical Preparation Form is considered homework in which the student prepares to give nursing care
by first reviewing pertinent aspects of patient care specific to the patient selected during the clinical
experience. The worksheet must be completed prior to the beginning of the clinical learning experience.
There are a number of sections to this worksheet and each section is to be completed. The following are
the directions for completing the worksheet. If you have any questions about completing the worksheet
or regarding instructor comments on you work, please contact your clinical instructor as soon as possible.
Submit electronically, unless specified otherwise by your clinical instructor.
Student/Date: Include your full name and the date of the clinical experience
Patient Initials/Medical Record Number/Ethnic or Cultural Background: Do not use the name of the
patient, use only the patient's initials and medical record number. Don't forget to include information
about your patient's cultural background.
Admission Date: Identify the date of admission to the hospital.
Admitting Diagnosis: Identify the admitting diagnoses of the patient.
Other Diagnosis/Surgical Procedures: Look on the H&P, the admitting note, the nursing history and the
operative note. If applicable identify all medical diagnosis and surgical procedures done currently or in
the past.
Allergies: Note specific allergies. If none, write "none" or NKDA"
Diet: Identify the specific diet for patient
Intake and Output (I & O): Indicate if the patient is on I & O includes all pts. receiving IV therapy
IV: Indicate the type and location of IV, type of solution and the rate per hour.
Invasive Tubes: Indicate any invasive tubes that are present.
Pertinent Laboratory & Diagnostic Information: Identify the date of the lab work, low or high values
accompanied by arrows up or down to demonstrate the trend.
Medications: Identify the name of the drug, both generic and trade, mechanism of action, side effects,
rationale, and nursing implication and patient teaching. This should be done for every medication the
patient is receiving. Use your drug book.
Patient Care Plan: Review the pt. care plan for accuracy and thoroughness. Make any changes you feel
are appropriate. For example, add a problem which you feel needs to be included. Describe the expected
outcome and the appropriate nursing interventions.

N4810 Clinical Paperwork Rev 11/6/13

CSU, STANISLAUS B.S.N.

CLINICAL PLAN OF CARE
Patient Data
Student: Harpreet Kaur Date of Care: 11/13 - 14/14 Room Number :17 Code Status: Full code by default
Pt. Initials Gender: Age Height: 50 Weight: 149lb BMI Spirituality:

Ethnicity:

Admitting Diagnosis: Endocarditis of mitral valve Vital Signs: Temp: 36.2 HR 90 RR 20 BP: 156/92 O2 Sat: 94 Pain Scale & Scale Type: Denies
Pain, Adult number scale.
History related to this admission: Pt transferred from Los Banos on 11/6/14. Presented with shortness of breath and respiratory distress. Pt was
hypoxic. However, husband refused intubation. Pt was placed on BiPAP and showed improvement. BP was in the 180s. Gave sublingual
Nitroglycerin. BP dropped in the 80s. Gave 3 IV fluids. Still remained hypotensive with systolic BP in the 80s. Pt. had previous multiple
hospitalizations due to bacteremia. Now has diarrhea.
Hospital Problem list: IV drug abuse, Hypothyroidism, HTN, Respiratory failure, PNA, Sepsis, Lactic Acid, Hypotension, Acute Encephalopathy,
Acute diarrhea, Acute on chronic respiratory failure, COPD.
Past Medical History: Chronic Airway obstruction unspecified essential HTN, Asthma, Sepsis, Hypothyroidism, HTN, Leukocytosis, and Hepatitis.
Admit Date: 11/6/14 POD: N/A
Surgical History & Date: Hysterectomy, Liver tumor removed. MD(s): Tesfaye, B.
Non Hospital Problem: UTI, Sepsis, Staphylococcus aureus bacteremia, Cerebral ischemia, Acute encephalopathy, Leukocytosis, Acute renal
failure w/hypoxia, Pneumonia, Hypernatremia, Endocarditis, Anemia, CVA, NSTEMI, Hypotension, Hypomagnesaemia, Diarrhea, Fluid overload,
Mitral valve regurgitation.
Diet : Regular
Activity: Ambulate w/1 person assist
Foley : None Feeding Tube & Rate: None
Advance Directive: Yes ________ No ___X___
Drains/ Tubes: None
Isolation : contact for c-diff VS Freq: Q4HR
Glucose Monitoring: None DVT Prophylaxis : SCD while resting; Lovenox
Vascular Access: Central line IJ triple lumen
PCA/Epidural: None Telemetry & Rhythm: continuous, NSR
IV Site: N/A IV Solution & Rate: N/A
Safety Considerations: Side rails, Fall precautions. Restraints: None
IV Site: N/A IV Solution & Rate: N/A Labs for day of clinical: 11/12/14Vancomycin trough 30 minutes prior to 1600 dose; Potassium Routine PRN
2 hours after replacement complete,11/12/14: Basic Metabolic Panel w/GFR; CBC w/ Automated Differential
Dressing Changes & Frequency: PICC line Q7days
Scheduled Procedures: Repair of tricuspid and mitral value on 11/15/2014
Procedures done this admission: EKG, CT Chest, Heart Catheterization, Echocardiograms, NIVL, and NM
Oxygen: Room air
Respiratory Treatment: Ipratropium/ Albuterol (Duoneb) 0.5mg/2.5mg/3mL Nebsoln Q4H PRN
Vent Settings: BiPAP ventilator non- invasive. Ipap:12; Epap: 8; Pressure support: 4; Set rate: 10; Tidal volume:156; Minute ventilation: 10.
Advanced Hemodynamic Monitoring & Values: None
IV Drips Medications Dosage & Rate: None

Medication
Generic & Trade Name
Dose, Route, Frequency
Atorvastatin (Lipitor)
Tab 10 mg oral daily.

Clonazepam (Klonopin)
Tab 0.5 mg Oral BID

Enoxaparin (Lovenox)
Inj 40 mg Subcut Q12 H

Famotidine (Pepcid)
20 mg oral BID

Fluticasone/Salmeterol
(Advair Diskus)
250mcg/50 mcg oral
inhaler 1 puff oral BID

Mechanism of Action
Classification
Lipid-lowering agents.
Lowers total and LDL
cholesterol and triglycerides.
Increases HDL cholesterol.
Slows the progression of
coronary atherosclerosis
decreasing coronary heart
diseaserelated events.
Benzodiazepine produces
sedative effects in the CNS.

Patient-Specific Rationale

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

Moderate bilateral
plaguing in carotid artery
showed on NIVL Duplex
Scan Extra cranial
Bilateral.

S/E abdominal pain, constipation, diarrhea, flatus,

heartburn, rashes, Rhabdomyolysis, angioneurotic edema.
- Monitor LFTs prior to initiation of therapy.
- Avoid grape juice with this medication.
- Notify HCP if unexplained muscle pain, tenderness, or
weakness occurs.

Patient experienced severe S/E suicidal thoughts, behavioral changes, drowsiness,

anxiety on my shift on both ataxia, fever.
days.
- Assess degree and manifestations of anxiety.
- Assess for drowsiness and clumsiness.
- Monitor for suicidal thoughts.
Anticoagulants - Prevention
Used as a DVT prophylaxis S/E bleeding, anemia, edema, hyperkalemia.
of thrombus formation.
- Assess for bleeding and hemorrhage.
- Monitor CBC, platelet count, and stools for potential
bleeding.
- Advise to report unusual bleeding, or bruising,
dizziness, rash, fever, swelling, or difficulty breathing.
Antiulcer agents decreases GI prophylaxis
S/E confusion, dizziness, arrhythmias, agranulocytosis.
secretion of gastric acid
- Monitor CBC during therapy.
- Monitor ALT, AST, and Creatinine.
- administer with meals or immediately after.
- Advise pt to report black, tarry stools, and sore throat.
Fluticasone is a steroid that
Pt. has COPD and came in S/E black tarry stool, blurred vision, cough, headaches,
prevents the release of
to the hospital with
unusual bleeding.
substances that release
respiratory distress
- Assess BP, HR, RR, O2 before and after therapy.
inflammation. Salmeterol is a
- Advise patient to change position slowly as this med
bronchodilator that relaxes
may cause dizziness and blurred vision.
muscles in the airway to aid
- Advise patient to rinse mouth after therapy to avoid
breathing.
getting oral thrush.

Furosemide (Lasix)
40 mg oral BID

Increases renal excretion of

water, sodium, chloride,
magnesium, potassium, and
calcium.

Pt. has fluid overload as

evidenced by peripheral
edema +2 (on feet
bilaterally) and diminished
bases

Ipratropium/ Albuterol
(Duoneb)
0.5mg/2.5mg/3mL
Nebsoln Q4H PRN

relax muscles in the airways

and increase air flow to the
lungs.

Pt. presented with

respiratory distress and
SOB. Pt. has respiratory
failure and pneumonia.

Labetalol
(Normodyne/Trandate)
Inj 10 mg Q6H PRN

Antihypertensive - Blocks
stimulation of beta1
(myocardial)- and beta2
(pulmonary, vascular, and
uterine)-adrenergic receptor
sites.

Pt. presented with

hypertension. Also patient
has pericardial effusion
that increases the workload
of the heart; thus this med
can decrease the workload.

Lactobacillus Acidophilus
(Floranex, Probiata)
Tab TID

Maintains an acidic
environment in the body to
prevent growth of harmful
bacteria.
Hormones replacement in
hypothyroidism to restore
normal hormonal balance

Pt. had diarrhea and this

medication is used for
treating and preventing
diarrhea.
Pt. has hypothyroidism

Levothyroxine
Tab 50 mcg. Oral Daily. 1
hr before bkfst

S/E - constipation, dehydration, hypocalcemia,

hypochloremia, hypokalemia, hypomagnesemia,
hyponatremia, hypovolemia, metabolic alkalosis
- Assess patient for skin rash frequently during therapy.
- Commonly serum potassium. May cause serum
sodium, calcium, and magnesium concentrations. May
also cause BUN, serum glucose, Creatinine, and uric
acid levels.
- Monitor BP and pulse before and during administration.
- Monitor daily weight, intake and output ratios, amount
and location of edema, lung sounds, skin turgor, and
mucous membranes.
S/E - Dizziness, nausea, dry mouth, constipation,
headache.
- Assess respiratory status (rate, breath sounds, degree of
dyspnea, pulse) before administration and at peak of
medication.
- Advise patient to inform health care professional if
cough, nervousness, headache, dizziness, nausea, or GI
distress occurs
S/E fatigue, weakness, hyperglycemia, hypoglycemia,
CHF, Bradycardia, pulmonary edema.
- Monitor BP and pulse during therapy.
- Monitor I/O, daily weight.
- May cause increase in blood glucose, alkaline
phosphate, ALT, AST.
- Monitor for drowsiness, dizziness.
S/E allergic reactions hives, difficulty breathing,
swelling of face, lips, tongue or throat.
S/E None when given proper dose.
- Assess apical pulse and BP before and after treatment.
- Monitor thyroid function studies.
- Advise patient to notify health care professional if
headache, nervousness, diarrhea, excessive sweating, heat
intolerance, chest pain, increased pulse rate, palpitations.

Lisinopril
(prinvil, Zestril)
Tab 10 mg oral daily

Antihypertensive lowering
of BP in hypertensive
patients

Lorazepam (Ativan)
0.5 mg Q4H PRN

Anti-anxiety: potentiating
GABA to decrease anxiety

Magnesium Oxide
(Magox)
Tab 400 mg TID w/meals.

Mineral and Electrolyte

replacements play an
important role in
neurotransmission and
muscle excitability.

Metoprolol Tartrate
(Lopressor)
Tab 12.5 mg oral BID

Anti-hypertensive - Blocks
stimulation of beta1
(myocardial)-adrenergic
receptors. Does not usually
affect beta2 (pulmonary,
vascular, uterine)-adrenergic
receptor sites.
Anti-infective - Disrupts
Pt. has endocarditis, C-diff,
DNA and protein synthesis in and Sepsis.
susceptible organisms.

Metronidazole (Flagyl)
500 mg in 0.79 % NaCl
100 mL (Premix) IV Q8H

Nitroglycerin SL
(Nitrostat)
Tab 0.4 mg Sublingual
Q5min PRN

Pt presented with
hypertension upon
admission and has a hx of
hypertension. BP on both
days of clinical stayed
around 150/90s.
Patient experienced severe
anxiety on my shift on both
days.
Pt. has hx of
hypomagnesaemia and has
diarrhea that may cause
loss of electrolytes. Pt. is
also getting Lasix that
might further aid this loss.
Pt. presented with
hypertension. Also patient
has pericardial effusion
that increases the workload
of the heart; thus this med
can decrease the workload.

S/E dizziness, cough, hypotension, N/A, hyperkalemia.

- Monitor BP before and after administration.
- Monitor weight to assess for fluid overload.
- Assess for drowsiness and dizziness.
S/E dizziness, drowsiness, lethargy, respiratory
depression, apnea, cardiac arrest.
- Monitor patient for increased drowsiness and dizziness.
- Monitor respiratory rate and effort before and after
administration of medication.
S/E diarrhea, flushing, sweating.
- Assess for s/sx of hypomagnesaemia.
- Monitor magnesium level and renal function before and
after administration.

S/E fatigue, weakness, bradycardia, hyperglycemia, and

hypoglycemia.
- Monitor BP, ECG, and pulse frequently during dose
adjustment and periodically during therapy.
- Monitor I/O and daily weights.
- Watch for slow pulse, difficulty breathing, sore throat,
unusual bleeding.
S/E Dizziness, headache, abdominal pain,
nausea/vomiting, and leukopenia.
- Assess for infection ( VS, sputum, stool, WBCs, and
stool)
- May alter LFTs.
- Inform patient that this med may turn the urine dark.
Produces vasodilation
Pt. presented with high
- Assess location, duration, intensity, and precipitating
(venous greater than arterial). blood pressure. BP on both factors of patient's anginal pain.
days of clinical stayed
- Monitor BP and pulse before and after administration.
around 150/90s.
Patients receiving IV nitroglycerin require continuous
ECG and BP monitoring. Additional hemodynamic
parameters may be monitored.
May cause falsely serum cholesterol levels.

Ondansetron (Zofran)
2mg/mL Inj 4 mg Q6H
PRN

Blocks the effects of

serotonin at 5-HT3receptor
sites (selective antagonist)
located in vagal nerve
terminals and the
chemoreceptor trigger zone
in the CNS.

PRN for nausea/vomiting

that might be caused by
other medications side
effects.

- Assess patient for nausea, vomiting, abdominal

distention, and bowel sounds prior to and following
administration.
- Monitor ECG in patients with hypokalemia,
hypomagnesemia, HF, bradyarrhythmias, or patients
taking concomitant medications that prolong the QT
interval.
- May cause transient in serum bilirubin, AST, and ALT
levels.
Oxycodone (Roxicodone) Opioids - Alters the
Moderate to severe pain.
S/E confusion, sedation, respiratory depression,
tab 10 mg oral Q4H PRN perception of and response to The previous shift on 11/13 constipation, urinary retention, N/V
painful stimuli, while
reported that patient often
- Assess BP, pulse, and respirations before and
producing generalized CNS
complains about lower
periodically during administration.
depression.
back pain.
- Assess type, location, and intensity of pain.
- Assess bowel function routinely.
Pneumococcal Polyvalent Indicated to provide active
Pt qualifies for this vaccine S.E pain, warmth, soreness, redness, swelling at the
(Pneumovax 23) Vaccine immunization for the
as this med is given to
injection site; headache, weakness, muscle pain.
0.5 mL IM
prevention of pneumococcal people over 50 years and
- Advise the patient to report if they experience any of the
Disease.
older and those are at risk
side effects listed above.
for infections.
Potassium Chloride
Maintain acid-base balance,
For potassium less than or
- Assess for signs and symptoms of hypokalemia
10mEq in 100 mL sterile
isotonicity, and
equal to 2.9. Also, pt has
(weakness, fatigue, U wave on ECG, arrhythmias,
water IVPB (premix) IV
electrophysiologic balance of diarrhea that might cause
polyuria, polydipsia) and hyperkalemia.
PRN
the cell.
loss of electrolytes. She is
- Monitor serum potassium before and periodically during
also getting diuretics
therapy. Monitor renal function, serum bicarbonate, and
therapy.
pH.
Prednisolone
tab 40 mg oral daily
w/breakfast

Anti-inflammatory Pt. has sepsis that is an

suppresses inflammation and inflammatory response to
the normal immune response. infection. Pt has several
infection including
endocarditis, pneumonia,
and C-diff.

S/E depression, euphoria, hypertension, adrenal

suppression, muscle wasting.
- Assess patient for signs of adrenal insufficiency
(hypotension, weight loss, weakness, nausea, vomiting,
anorexia, lethargy, confusion, restlessness) prior to and
periodically during therapy.
- Monitor intake and output ratios and daily weights.
Observe patient for peripheral edema, steady weight
gain, rales/crackles, or dyspnea.

Temazepam (Restoril) Cap Benzodiazepine - Acts at

15mg Bedtime PRN
many levels in the CNS,
producing generalized
depression.

PRN Sleep

Tiotropium (Spiriva)
Dose 1 cap oral inhalation
Daily

Bronchodilator - Acts as
Pt. has respiratory failure
anticholinergic by selectively and pneumonia
and reversibly inhibiting M3
receptors in smooth muscle
of airways.

Vancomycin (Vancocin)
50 mg/mL Oral Soln
Compounded 250 mg oral
Q6H

Treatment of potentially lifethreatening infections when

less toxic anti-infectives are
contraindicated.

Pt. has sepsis possibly due

to pneumonia, C-diff, and
endocarditis.

Vancomycin 650 mg in
Nacl 0.9% 150 mL IV
Q12H

See above

See above

S/E lethargy, drowsiness, diarrhea, N/V

- Assess mental status (orientation, mood, behavior) and
potential for abuse prior to administering medication.
- Assess sleep patterns before and periodically throughout
therapy.
- Prolonged high-dose therapy may lead to psychological
or physical dependence. Restrict amount of drug available
to patient, especially if patient is depressed or suicidal or
has a history of addiction.
S/E urinary difficulty, rash, glaucoma.
- Advise patient to notify health care professional
immediately if signs and symptoms of angioedema
(swelling of the lips, tongue, or throat, itching, rash.
- Assess respiratory status (rate, breath sounds, degree of
dyspnea, pulse) before administration and at peak of
medication.
S/E - Ototoxicity, nephrotoxicity, rashes, phlebitis, N/V
- Monitor IV site closely for tissue necrosis
- Assess patient for infection (vital signs; appearance of
wound, sputum, urine, and stool; WBC) at beginning of
and throughout therapy.
- Monitor intake and output ratios and daily weight.
Cloudy or pink urine may be a sign of nephrotoxicity.
- Assess patient for signs of superinfection (black, furry
overgrowth on tongue; loose or foul-smelling stools).
- Observe patient for signs and symptoms of anaphylaxis
(rash, pruritus, laryngeal edema, wheezing).
- May cause increased BUN levels.
See above

LABORATORY DATA

LABS

Normal Range
(Fill in Hospital Norms)

MEDICATION WORKSHEET
RESULT 1
(11/9/11 @0400)

RESULT 2

RESULT 3

(11/11/14
@0235)

(date & time)

CBC

WBC

4-11

11.8

12.8 H

RBC

3.9-4.67

3.28

3.54- L

Reason for abnormal lab

values r/t diagnosis &
nursing implications

Elevated levels are due

to infection. Pt. has
sepsis possibly due to
pneumonia, C-diff, and
endocarditis. Pt. also has
c-diff and a hx of
leukocytosis
Low levels could be due
to anemia and renal
disease. Pt has hx of
anemia and acute renal
failure.

Allergies: Acetaminophen, Codeine hydrochloride Anaphylaxis, Penicillins Rash,

urticarial.

Hemoglobin

13-18

9.4

10.5- L

Hematocrit

40-52

30.5

32.9- L

80-100
27-33
31-36
<16.4

93
28.7
30.8
20.3

93
29.7
31.9
20.8-H

150-400

182

202

49-74

87-H

73

Neutrophils kill and

digest bacterial
organisms. Elevated
levels could be due to
sepsis.

26-46

17-L

Low levels of
lymphocyte could be
due to sepsis and
radiation therapy. Pt had
a hx of liver tumor.

2-12

10

136-145
3.5-5.1
98- 107

142
4.6
115

144
4.0
114- H

70-100

136

118

MCV
MCH
MCHC
RDW

PLT COUNT
WBC DIFF
NEUTROPHIL %

BANDS %
LYMPHOCYTE%

MONOCYTE %
CHEMISTRY
Sodium
Potassium
Chloride

CO2(bicarb)venous
Glucose

Low levels could be due

to anemia and renal
disease. Pt has hx of
anemia and acute renal
failure.
Low levels could be due
to anemia and renal
disease. Pt has hx of
anemia and acute renal
failure.

RDW is an indication of
the variation in RBC
size. Elevated levels
could be due to anemia
as RBC fragmentation
alters RBC size and
shape.

Elevated chloride could

be due to kidney
dysfunction. Pt. has
acute renal failure.
Elevated levels could be
d/t sepsis = stress
mediated cortisol and
catecholamine release
from sepsis, resulting in
the increased
mobilization of

glycogen stores,
gluconeogenesis, and
the subsequent
production of glucose.
They could also be
elevated d/t acute renal
failure and diuretic
therapy.
Calcium
phosphorus
Magnesium
HDL
LDL
Cholesterol
Triglycerides
BUN

8.2-10.2

7.7

8.0

1.8- 2.4

2.3

1.8

6-25

27

25

Creatinine
Vanco Trough
LIVER PANEL
Total protein
Albumin

0.4-0.8
10-20

0.54

6.4-8.2
3.2-4.7

0.62
19.8
11/8 0140
6.1
2.2

Bilirubin Total
Alk phosphatase
AST

0-1.1
26-137
0-37

0.7
63
108

ALT

0-60

100

Lipase
Amylase
Ammonia
Lactate
Serum Ketones
CARDIAC PANEL
CPK

Bun represents kidney

function. Previous
Slightly elevated level
could be d/t acute renal
failure.

Albumin is synthesized
in the liver. Low
albumin could be d/t hx
of smoking, liver tumor,
hepatitis, cirrhosis and
acute renal failure.
Elevated levels indicate
liver dysfunction. Pt has
a hx of smoking, liver
tumor, cirrhosis, and
hepatitis.
Elevated levels indicate
liver dysfunction. Pt has
a hx of smoking, liver
tumor, cirrhosis, and
hepatitis.

CPK-MB
Troponin
Myoglobin
BNP
COAGULATTION
PT

0-0.05

0.03

12.1 15.3

11/6 0750
16.4

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

0.9-1.1

1.4

Yellow

Unknown
Amber

Urine appearance

Clear

SI cloudy

Specific gravity
Urine Ph
Urine glucose

1.005-1.030
4.6- 8.0
Neg

1.018
5
Trace

Urine bilirubin
Urine blood

Neg
Neg

Neg
Large

Coagulation factors are

made in the liver.
Elevated levels could be
due to hepatitis, liver
tumor, cirrhosis, and hx
of smoking.

Concentrated urine may

lead to amber color.
Lack of sufficient water
intake may lead to
concentrated urine.
Urine sample placed in
the fridge for more than
an hour could cause it to
become cloudy.
Normally there is no
glucose present in the
urine. Glucose in the
urine may be present
because the liver is not
breaking it down (d/t hx
of liver tumor, cirrhosis,
and hepatitis) and the
kidneys are not able to
filter them back in the
blood (acute renal
failure).
Presence of blood in
urine could be due to
traumatic catheterization
(removed catheter on
11/10) and liver
dysfunction (hx of
smoking, hepatitis,
cirrhosis, and liver
tumor).

Urine Ketones

Neg

Trace

Urine Nitrites
Urine Protein

None
None

Neg
100

Urine Leukocytes
URINE MICRO
WBC HPF
RBC HPF

None

Neg

0-5
0-2

3
20

none

None
None
none

Nitrate HPF
Epithelial
Bacteria
Mucous
URINE CULTURE
CSF
WBC
RBC
Glucose
Protein
Culture

Normally, no ketones
are present in the urine;
however, a patient with
poorly controlled
hyperglycemia may
have massive fatty acid
catabolism. The purpose
of this catabolism is to
provide an energy
source when glucose
cannot be transferred
into the cell because of
insulin insufficiency. Pt.
had high glucose levels
and liver dysfunction
(hx. Of smoking,
hepatitis, cirrhosis, and
liver tumor) that cant
break down the glucose
effectively.
Possible protein in urine
might be an indication
of livers insufficiency
in breaking it down and
kidneys insufficiency in
filtering them (pt. has
acute renal failure).

Presence of blood in
urine could be due to
traumatic catheterization
(removed catheter on
11/10) and liver
dysfunction.

Blood Cultures 11/6

0755
Stool Cultures- 11/6
1715
Nasal Cultures 11/6
1600
ABG(FIO2 + device)

No growth as
of 11/11
C-diff Toxin
MRSA - Neg
11/ 6 2046

pH
PO2
PCO2

7.35-7.45
80-100
35-45

7.399
96
26.5

Bicarbonate

22-26

16

Oxygen Saturation
Anion gap
Lactate

95-100

97

0.4-2.0

3.2

DIAGNOSTIC DATA
____________________

ECG 11/14/14
11/6/14 - X ray chest portable

ABGs = Metabolic
acidosis compensated
Decreased pco2 occurs
with hyperventilation.
Following factors could
have contributed for
patient hyperventilating:
respiratory distress
(SOB and increased
WOB), anxiety, and
pain.
Decreased HCo3 levels
could be d/t pt. having
diarrhea and acute renal
failure.
With normal oxygen,
glucose is metabolized
to CO2 and H2O for
energy. When oxygen to
the tissues is
diminished, anaerobic
metabolism of glucose
occurs, and lactate
(lactic acid) is formed
instead of CO2 and H2O.
To compound the
problem of lactic acid
buildup, when the liver
is hypoxic, it fails to
clear the lactic acid.
Pt. has hx of smoking,
liver tumor, cirrhosis,
and hepatitis.

Student Name:
Normal sinus rhythm w/ one PVC
Indication: central line placement. No

11/6/14 Transthoracic Echocardiogram

10/13/14 Transesophageal Echocardiogram

9/13/14 CT chest without contrast

9/1/14 NIVL Duplex Scan Extra cranial Bilateral

complete
9/5/14 NM Lung ventilation and perfusion
11/4/14 Heart catheterization

pneumothorax
Normal LV size and systolic function.
Left atrial enlargement.
Mild mitral regurgitation with normal PA pressure.
Mitral valve is calcified.
Moderate to severe tricuspid regurgitation
Severe anteriorly directed mitral regurgitation.
Possible old focal calcified vegetation on atrial
surface on posterior mitral valve.
Moderate tricuspid regurgitation.
Mild aortic regurgitation.
No evidence of clot in cardiac chambers.
New large pericardial effusion.
Hepatic cirrhosis.
Mild nonspecific mediastinal and upper abdominal
lymphadenopathy, stable.
Moderate bilateral plaguing. No evidence of
hemodynamically significant disease.
Low probability of PE. Airway disease
predominantly in left lung
Normal coronary angiogram.
Severe mitral regurgitation.
Normal LV function with ejection fraction 60%.
Mild pulmonary HTN.

1. Impaired gas exchange

Data to support: SOB, airway disease (NM lung
ventilation and perfusion), respiratory distress,
COPD, diminished bases, pulmonary HTN,
elevated lactate (3.2)
Interventions: Lasix, Advair, Duoneb, Spiriva,
BiPAP; Monitor RR, depth, and rhythm;
Auscultate lung/breath sounds Q4H; Check skin
for signs of cyanosis, Encourage activity as
tolerated; Monitor mental status for onset of
restlessness, agitation and confusion; Monitor
arterial blood gases (ABGs) and note changes;
Assess lung sounds, noting areas of decreased
ventilation and the presence of adventitious
sounds; Note color, quantity, and amount of
sputum; Encourage coughing and deep breathing.

6. Risk for Imbalanced nutrition

Data to support: pt. described lack of interest in
food, reported altered taste sensation especially
after taking oral vancomycin, loose stool until
11/12/14, loose/formed stool on 11/13 -14/14
denied breakfast and lunch on 11/14/14, easily
bruised, low albumin (2.2)
Interventions: Monitor for signs of malnutrition
including: brittle hair that is easily plucked,
bruises, dry skin, pale skin and conjunctiva,
muscle wasting, smooth red tongue, cheilosis,
flaky paint rash over lower extremities, and
disorientation
- Monitor percentage of food that is eaten.
- Avoid interruptions during mealtime.
- Provide good oral hygiene before meals to
improve the taste.
- Note laboratory test results as available: serum
albumin, prealbumin, serum total protein, serum
ferritin, transferrin, hemoglobin, hematocrit, and
electrolytes

2. Decreased cardiac output

Data to support: pericardial effusion; mitral, tricuspid, and
aortic regurgitation; pulmonary HTN, vegetative mitral
valve, fluid overload, +2 edema on feet bilaterally, +1 pedal
pulses, prolonged capillary refill, BP 156/92, heart murmur
detected, occasional PVC.
Interventions: Monitor cardiac rhythm; Monitor VS
especially lung sounds, heart sounds, O2 sat, give oxygen
when SOB or when s/sx of hypoxia are present; monitor
I&O; Encourage semi-Fowlers or high Fowler to decrease
WOB & lower preload to decrease heart workload; Provide
cluster care; Assess for anxiety which can increase HR and
administer Ativan, Klonopin, and Tamezapam as
prescribed; - Check BP, pulse before administering
Metoprolol, lisinopril, and nitroglycerin as prescribed.

Chief Medical diagnosis: Endocarditis

of mitral valve; sepsis; and respiratory
failure.
Priority assessment airway, breathing,
circulation, Vital signs, pain, lungs
sounds, heart sounds, labs (WBCs,
ABGs, PT, INR,) pulses (pedal and
radial), telemetry monitoring.
5. Risk for Fluid imbalance
Data to support: Diuretic therapy (Lasix), prolonged cap
refill, increased turgor, weak bilateral pulse (pedal pulse
+1), acute renal failure, diminished bases, pericardial
effusion, regurgitation of mitral, tricuspid, and aortic
valve, had severe diarrhea until 11/12/14.
Interventions:
Monitor I/O, daily weights, lung sounds/ Heart sounds
(Q4H), EKG changes, HR, BP, pulse, RR
- Monitor the client's behavior for restlessness, anxiety, or
confusion; use safety precautions
- Monitor Electrolytes (Na, CL, K, Mg) BUN and
Creatinine.
- Monitor for abdominal distention and discomfort.
- Assess for neurological changes (LOC and mental
status)

3. Ineffective Tissue Perfusion

Data to support: prolonged cap refill (>3
seconds), weak pulses bilaterally (pedal and
radial pulses +1), slow skin turgor, pulmonary
HTN, Renal failure, cold and dry extremities;
heart unable to perfuse effectively d/t pericardial
effusion, regurgitation of mitral, tricuspid, and
aortic valve; BP 156/92, easy bruising (bruise
around face after using BiPAP mask).
Interventions:
Monitor I/O
- Assess Lung sounds/ heart sounds Q4H, cap
refill, peripheral pulses, turgor.
- Assess for skin breakdown.
- DVT prophylaxis SCDs, Lovenox.
- Encourage active ROM

4. Anxiety
Data to support: pt. had several periods of anxiety
throughout the shift, she got anxious about having
loose stool and not being able to have the surgery
(tricuspid and mitral valve repairmen) on 11/15/14.
Also, she got anxious about getting subcutaneous
shot. When she gets anxious, she gets SOB,
increased WOB, increased BP (156/92), restless,
Interventions:
- Klonopin, Tamezapam, and Ativan
- Encourage pursued lip breathing.
- Answer any questions that might be causing the
anxiety.
- Assess the client's level of anxiety and physical
reactions to anxiety (e.g., tachycardia, tachypnea,
nonverbal expressions of anxiety)
- Provide back rub/massage to relieve anxiety.
- Distract when performing invasive procedure
(Subcutaneous shots)

Problem Evaluation
Problem #
1

Evaluation of Patient Response

Pt. experienced shortness of breath whenever she was anxious. Administered

Advair and Duoneb @0900 on 11/13-14/14. Lung sounds diminished bases.
Skin- dry with ecchymosis on the face and upper extremities bilaterally.
Encouraged activity patient ambulated in the hall w/husbands assistance. Deep
breathing encouraged patient does it independently. ABGS on the 11/6 pH
7.399; pO2 96; pCO2 26.5; Hco3 16 = Metabolic acidosis fully compensated.
Patients cardiac rhythm remained NSR with occasional PVCs. VS WNL except
high BP 156/92. It stayed high during both days of clinical. She was given Lasix,
Lisinopril, and Lopressor. I encouraged her to try semi-fowler or fowlers position
to help decrease the workload on the heart. I 1800, O 1500.
I 1800, O 1500. Lung sounds diminished bases. Prolonged cap refill (>3
sec). Weak (+1) pulses bilaterally. Administered Lovenox as DVT prophylaxis.
Patient ambulated w/ husbands assistance.
Administered Klonopin for anxiety. Answered her questions to relieve any
anxiety. Husband massaged her back as she was short of breath. He also distracted
her when I was administering Lovenox subcutaneously.
Electrolytes WNL except Chloride (114). Diarrhea started improving on 11/13/14.
She was getting slightly formed stool. LOC and mental status WNL. No signs
of abdominal distention and discomfort.
No signs of malnutrition noted except dry skin. She denied breakfast and lunch on
both days of clinical; however, her husband was able to have her try little amount
of cereal and some snacks. As of 11/11, her albumin was low (2.2).

Student Clinical Self-Appraisal

EXAMPLE
Weekly (turn in with Care Plan/Map)
Student Harpreet Kaur 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 (11/13-14/14)

Ability to Prioritize: Running back and
forth between two patients was a bit
challenging; however, I was able to
handle it due to the nurses co-operation.
I told the nurses what time I could do the
meds, VS, assist the patients with ADLs,
etc. The nurses didnt mind and worked
well with me.
Communication/rapport: I feel my
conversation skills have improved very
much since the beginning of nursing
school. I realized this when RS and her
husband thanked me and said if there
was a nursing student award, we would
give it to you. This was the highlight of
the day. According to me, all I did was
give them my attention, communicate
what were doing for them, and answer
any questions.
Well-prepared: I felt I was well prepared
for both days of clinical, as I looked up
the meds for the day right when I got to
the floor. For this patient, the nurse asked
me which meds were due at what time. I
felt organized as I noted all the meds on
a piece of paper so she could easily pull
them from the med cart or Pixus.

Flexible
Coordinator of Care
Team Player
Educator
Ability to Prioritize
Knowledgeable

Areas Needing Growth-Include plan of

improvement
Technical skills: Although my skills of
drawing up medications in a syringe
have improved, I am still slow at this
process. I think its perhaps my fear of
sharp objects that makes me very
conscious. However, I am working on
improving it and get a little faster.
Educator: When the patient and her
husband had questions, I was not very
confident in answering them. Before
telling them anything, I checked with
nurse to confirm my answers. I feel this
is something I can improve on.

Instructor Comments:

Students Name: _____________________ Pts Initials: _______

Date:____________

PLACE EKG STRIP HERE

Atrial rhythm: Regular or

Irregular

Ventricular rhythm: Regular or

Irregular

Atrial Rate____________________

Ventricular rate _______________________

PR interval ___________________

QRS interval ________________

QT interval____________________
Is AV conduction normal? (Y/N)______________ If not, why is it abnormal?
________________________________________________________________________
P wave normal? (Y/N) ________

QRS complex normal? (Y/N) ________

Are all of the QRS complexes the same? (Y/N) ___________________

Are there premature beats? (Y/N) __________ , Atrial

or

ventricular

Interpretation of rhythm:
________________________________________________________________________
Potential hemodynamic consequences of this rhythm and interventions for this rhythm:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

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 _____

2.

Each medication includes:

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

20 points possible _____

3.

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

10 points possible _____

4.

Problem Identification includes

20 points possible _____
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 _____

6.

Evaluation of Interventions includes

a. Evaluates physical interventions
b. Evaluates teaching

10 points possible _____

7.

a.
b.

10 points possible ____

Priority Assessments are appropriate to diagnoses

Clinical Paperwork is complete

Total Points

_____________/100 = ____%