Lakeview College of Nursing
Clinical Preparation Assignment

Name: _Greg Cahill___ Date/Week: _9/25/12________ Adm. Diagnosis:_Cardiopulmonary arrest_______Allergies:__Codiene___________
                                                                                                                                                                                                                                  (pts)

Initials: _OB____Age: _56_____    Ht._5’9”__ Wt._220_____

Gender:  M    Ethnicity: _black__________

Occupation: _____does odd jobs like mowing______

Education: __highschool _______

Where do I live?     In the city with mom

Do I have any other family?  Mother and sisters visit frequently 

Admission Info: (why and how did I come to hospital):  passed out while driving and hit a truck

I have had these procedures while I have been here:  

I need help with:  all ADL’s  

I need help:                

I do not have a  DNR, POA, or Living Will. 

Activity Level:  non ambulatory, confined to bed , pt became aroused during shift and is alert and oriented x3, needs assistance with ADL’s

Medical History:  heart attack in march 2012, angioplasty, high cholesterol, HTN, sleep apnea, ulcers, renal disease, gout, DM 2, hepatitis C 

Surgical History:  
Shunts for dialysis, angioplasty 

What equipment am I using?  (Circle all that apply)

Foley       
 IV         
Telemetry   
  Oxygen- ventilator to nasal cannula 
 
Arterial line in L arm

I am rating my pain as a    
       ____0____/10. I describe it as

  
  LAB DATA    (List all pertinent/current lab/diagnostic values)                                                                                                                        (  pts)
TEST	NORMS	ON ADM	NOW	TEST	NORMS 	ON ADM	NO W	TEST	NORMS	ON 
ADM	NOW	
WBC	5-10	4.8	15.3 high	RBC	4.2-5.9	4.12	3.81	K	3.5-5	4.2	3.9	
DIFF: 
Monocytes

Lymphocytes

Neutrophils

Eosiniphils

Basophils	%
4-6

20-35

50-71

1-3

0.4-1
	%
2.4 low
12.1 low
85.2 high
0.1 low
0.2 low	%
5.1

21.5

67.0

0.1 low
0.3 low
	HGB/ HCT	12-16/40-48%	13/ 38.4 low	12.1/ 36.4 low	NA	135-145	138	139	
PT	<12	12.6 high	11.4	PLT	150-400	196	308	CL	95-105	90 low	99	
INR	.8-1.2	1.2	1.1	AST	<40	44	22	CA	8.5-10.5	8.2 low	9.1	
GLUCOSE				ALT	<40	34	17	CO2	24-32	59 high	33 high	
CHOLESTROL				BUN	10-20	64.0	60.0	MG	1.8-2.4	2.4	2.6 high	
TRIGLYCERIDE				CREATININE	.3-.5	11.5	7.9	Phosphorus	2.4 - 4.1	6.7 high	3.2	
HDL/LDL
				Troponin T			0.351	Amylase	25-160	288 high		
Ptt	25-35 second	31.2	34.2	CK-2		14.47		GFR	100-140	6 low	9 low	
DIAGNOSTICS:  Test & Results                                                                                                                                                                     
   Chest X-Ray:  shows cardiomegaly                    Other: CT with no contrast- no abnormalities seen                                                                        Other:
     
     EKG:  PVC’s                                                              Other:                                                                         Other:
	
CORRELATION: How does each abnormal test or lab relate to the diagnosis:   
HCT- low
WBC-monocytes, lymphocytes, neutrophils, eosinophils, basophils- infection 
PT-high – due to anticoagulants     
Cl- low- could be due to medications or dehydration
Ca- low- probably due to renal failure
CO2- high- due to poor ventilation and perfusion
Mg- high-due to kidney failure 
Phosphorus- high- phosphorus has an inverse relationship to Ca
Amylase-high- due to kidney failure
GFR- low- kidney failure         
Troponin T-heart damage
Ck-2 – heart damage                                                                        

	

Pathophysiology:  Review all data collected and describe what is happening at the cellular, organ, & system level, may use admitting or secondary diagnosis depending on Instructor preference.	Troponin T and Ck-2 are released when myocardial cells die (Porth, 2011). Cardiopulmonary arrest is an abrupt cessation of effective cardiac pumping activity and may be caused by MI, heart failure, dysrhythmia, coronary spasm or cardiac tamponade (Morton & Fontaine, 2009).  The decrease in circulation leaves the body short of O2 and nutrients.  The shortage of O2 can cause muscle death and brain damage and than total death.  The pt was in his car when he lost consciousness and was brought to the hospital promptly.  This allowed treatment to the pt very quickly.  Treatment included Amiodarone which is a non-competitive alpha and Beta-adrenergic inhibitor, that increases PR and QT intervals, decrease sinus rate, decrease sinus rate, decrease peripheral resistance (Mosby\'s 2012 nursing, 2012),  Carvedilol, a non selective Beta blocker and alpha blocker which lowers BP  and is used for left ventricular dysfunction after myocardial infarction (Mosby\'s 2012 nursing, 2012), O2, BLS and intubation.  A central and peripheral catheter was placed to facilitate drug therapy and TPN.  After the pt was stabilized he was put on levophed to increase BP.  The pt has a history of MI and is in end stage renal failure.
                                                      (pts)

 MEDICATIONS:                                                                                                                                                                       (pts)                     

List all medications ordered for your patient. Complete first four columns prior to clinical; last column MUST be completed at end of clinical session.

Name, dose & frequency of administration for this patient. Plus usual dose and frequency of prescription.	Classification & mechanism of action. [Use your drug guide!]	Why is medication ordered for THIS patient?	 Nursing Precautions/ Considerations with this medication. 	 Evaluate medication effectiveness for THIS patient (patient response).	
Protonix
40mg IV q 24hours

usual dose: 40 mg per day

Levophed
Usual dose; 0.5-1 mcg/min initially, followed by maintenance infusion of 2-12 mcg/min titrated by blood pressure response

Rocephin
1g  -1oo ml/hour
usual dose: 1-2 g every 12-24 hr

asa
325 mg q am
usual dose: 300-325 mg/day

Heparin
5000 units subcutaneous q 12hours
usual dose: 10,000 units, followed by 5000-10,000 units q 4-6 hr

Reglan
5mg iv BID
Usual dose: 10-15 mg qid 30 minutes before meals

Novolin R
subcutaneous
Sliding scale
Usual dose: pt dependant, give 15 minutes before or within 20 minutes after a meal

Amiodarone
450 mg/9ml vial, 16.6 ml/hour IV q 16hours

Carvedilol
6.25mg tablets BID
Usual dose 6.25 mg BID

Intralipid 20% 10.5 ml/hour IV
30ml/hour over 15-30 minutes

TPN 60 ml/hour 

(Mosby\'s 2012 nursing, 2012)	antiulcer agents
Pharmacologic: gastric acid pump inhibitors
binds to enzymes to make stomach acid not as acidic

vasopressor
alpha-adrenergic receptors agonist in blood vessels, causing constriction 

Therapeutic: anti-infectives
Pharmacologic: third-generation cephalosporins

Binds to cell walls- bactericidal 

antipyretics, nonopioid analgesics 
 salicylates

decreases platelet aggregation  

anticoagulant 

Potentiates the inhibitory effect of antithrombin on factor Xa and thrombin

Cholinergic, antiemetic

Central dopamine receptor antagonisk
Enhances response to acetylcholine of tissue in upper GI tract, shich causes contraction of gastric muscle

Antidiabetic
Decrease blood glucose by moving glucose into cells

Antidysrhythmic

Iodinated benzofuran derivative

Non-competitive alpha and Beta-adrenergic inhibitor, increases PR and QT intervals, decrease sinus rate, decrease sinus rate, decrease peripheral resistance

Non selective Beta blocker and alpha blocker

Fatty acid, nutritional supplement 

Nutrition deposited into the vein when patient unable to have nutritional intake through GI 

(Mosby\'s 2012 nursing, 2012)	To prevent ulcers

To raise blood pressure 

To treat infection

To prevent clots

To prevent DVT

Prevention of GERD

Diabetes mellitus II 

Dysrhythmia 

HTN, Left ventricular dysfunction after myocardial infarction

Increase caloric intake

Provide nutrition

(Mosby\'s 2012 nursing, 2012)	May cause Hyperglycemia, May ↑ risk of bleeding with warfarin

Monitor blood pressure

May increase AST, ALT, hemolytic anemia

Increased risk of bleeding

Increased risk of bleeding, thrombocytopenia, and anemia 

Side effects may include neutropenia, leukopenia, agranulocytosis,  dry mouth constipation

Acu-checks, Monitor for hypo/hyperglycemia

Hepatotoxic; assess for pulmonary toxicity, dyspnea, chest pain

Hepatotoxic, assess for hypotension, dizziness and bradycardia 

Assess for hyperlipemia, hypercoagulation, thrombocyopenia

Assess nutritional needs

(Mosby\'s 2012 nursing, 2012)	Effective ulcers present on emission but has not worsned

Effective
Blood pressure was 134/86

Effectiveness not yet known;
WBC count of 15300, infection still present 

Effective, no clots present

Effective no DVT present

Effective,   GERD not present

Effective DM II under control

Effective no dysrhythmia present 

Effective; BP 134/86

Effective, pt has adequate nutrition 

(Mosby\'s 2012 nursing, 2012)

PHYSICAL ASSESSMENT DATA      (COLLECT OWN DATA)                                                                                                   (pts)
Vital Signs:
Pulse Ox %: 96	BP:  134/86	Pulse:  84

Rhythm: regular with  PVC’s	Respirations:
Rate: 20
Depth: 500
Rhythm: regular	Temp:
99.8
Route: ear	Pain:
Rating:    0     /10    
Characteristics:  	
NEUROLOGICAL: 
 MAE:                PERLA:         
Strength Equal:   
Orientation, Mental Status, Speech, Sensory, LOC, 	MAE, PERL, equal strength, patient had wrist restraints until 930am,  pt has trouble speaking- pt extubated himself, may have damaged voice box, alert and oriented x3

	
MUSCULOSKELETAL: 
Neurovascular status, ROM, Supportive devices/strength

ADL Assistance           Fall Risk:       

Fall Score__________
Activity/Mobility Status
	Pt bedridden for past week, full ROM, needs help with all ADL’s,  pt was sitting up in bed by 10am, 	
CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: _____
Neck Vein Distention:         Edema    
Location of Edema____________________
	S1, S2 present, frequent PVC, begemeny at time, edema +1 in legs, capillary refill less than 3 seconds, pt undergoing dialysis every other day	
RESPIRATORY:
Accessory muscle use:        
Breath Sounds: Location, character	Pt extubated himself and then went from a rebreather mask to nasal cannula, O2 % is 96 on nasal canula at a 30% rate,  breath sounds diminished	
GASTROINTESTINAL:
Diet at home :  diabetic diet     Current Diet:    TPN

Height:                 Weight: 

Auscultation: Bowel sounds, other sounds
Last BM, character &  freq of stools 
Palpation: Pain, Mass etc
Inspection: distention, incisions, scars, drains, wounds
Ostomy:               Nasogastric:       
Feeding tubes/PEG tube           Type:___________
	Diet=TPN, pt is NPO, bowel sounds active x4, stomach is flat, nontender, no masses or pain present, diabetic diet at home, bowel movement 3 days ago	
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: _12_____
Drains present:             Type______	Skin is dry and color is appropriate for age and ethnicity,  risk for skin breakdown, pt was sitting up and moving by end of shift, pt on wrist restraints until 9am, mother put lotion on the  patient’s feet and legs.	
EENT: 
Ears:              Eyes: 
Nose:                        Teeth:  
                               	Nose: septum even, nostrils patent, ears: even, well shaped, no signs of HOH, Teeth: present, no sings of decay,  Eyes: pt has reading glasses but does not ware them all the time. 	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis      
Inspection of genitals
Catheter:        Type______
	Urine: yellow, clear; pt undergoes dialysis every other day
Genitals show no signs of infection or disfigurement 	
PSYCHOSOCIAL/CULTURAL:
Coping methods,          Educational level
Developmental level,       Ethnicity, 
Religion & what it means to pt.
Occupation (previous if retired)
Personal/Family Data    (Think about home environment, family structure, and available family support)	African American male,Pt  is a high school graduate, and works doing odd jobs like mowing, Pt is Baptist and volunteers at the church often, pt lives with mother.  Pt was only moderately conscious and farther information is hard to obtain at this point. 	
USE THE BACK OF THE SHEET FOR ADDITIONAL SPACE FOR DETAILS. EXPECTATIONS MAY VARY FOR DIFFFERENT COURSES

List ANY DATA/ FINDINGS i.e. Signs & Symptoms, Family Info, History etc. that have or could have any impact on the care for this client/patient.					                     (pts)

56 YOA black male

gout

O2 by NC  2L/min

History of MI in 2012

DM II

GFR low

Hepatitis C

Troponin t
Ck-2 elevated

Mg-high

End stage renal failure

Infection

Pt self extubated

Cardiopulmonary arrest

Ca -high

Pulse ox  96

Cardiomegaly 

 HTN

Anticoagulants 

HGB 11.9
HCT 35
RBC 3.6

Sleep apnea 

Ulcers

Amylase-high

Co2-high

Overweight

PT-high

angioplasty

WBC high

  Problem List                                            (pts)
                                                    	Nursing Concern/Diagnosis                                                               (pts)
One diagnosis may represent several problems	 Priority of  List          (pts )
  Use numbers	
heart attack in march 2012-a
 Angioplasty for CAD-a
 high cholesterol-d
 HTN-d
 sleep apnea-g
 Ulcers-f
 renal disease-f
 Gout-f
 DM 2-d
 hepatitis C
cardiopulmonary arrest-a,b
Infection
Nutrition-e
Overweight-d 	
A. Decreased Cardiac Output r/t cardiopulmonary arrest AEB edema 

b. Ineffective Breathing Pattern r/t cardiopulmonary arrest AEB diminished breath sounds and oxygen therapy

c. Activity Intolerance r/t cardiopulmonary arrest AEB the pt’s inability to do strenuous activity

d. Knowledge deficit r/t lack of information AEB: overweight,  htn, high cholesterol, DM II

e. Nutritional imbalance r/t NPO status AEB weight loss  

f. impaired nutritional status r/t renal disease AEB electrolyte imbalance

g. Disturbed sleep pattern r/t frequent awakening secondary to sleep apnea

1

2

4

5

3

6

7	

1st Priority Nursing Diagnosis:  (  pts)
Decreased cardiac output r/t cardiopulmonary arrest AEB edema																

2nd priority Nursing Diagnosis:
	
Ineffective breathing pattern r/t cardiopulmonary arrest AEB diminished breath sounds

Nursing Diagnosis (restated):

What does the patient/client need to accomplish?
GOALS/OUTCOMES
Nurse or client perspective
	What can the nurse do to help resolve the problem?
IMPLEMENTATION
Nursing Interventions  	Why will the nurse do these actions?

SCIENTIFIC RATIONALE
Be sure to include source using APA format	How did the patient/family respond to the nurse’s actions? 
EVALUATION
Client Response, Status of Goals & Outcomes, Modifications to Plan	

Ineffective breathing pattern r/t cardiopulmonary arrest AEB diminished breath sounds

Breath sounds continue to clear by 11am

Pt maintains an effective breathing pattern aeb: normal rate, rhythm, and depth of respirations by end of shift

Decreased cardiac output r/t cardiopulmonary arrest AEB edema

Increase activity tolerance 

Teaching pt about lifestyle changes: diet, exercise, medications, s/s of when to call the doctor  

Encourage use of incentive spirometer every hour

Suction excess mucus as needed

Administer 2-6 L/min O2 by nasal cannula as ordered

Have pt practice range of motion exercises

Have pt repeat what the nurse teaches him

Have pt state why life style changes are necessary 	

Incentive spirometer helps maintain maximum inspiratory effort (Crowe & Bradley, 1996)

Suctioning helps keep the airway patent (Crowe & Bradley, 1996)

ROM exercises help keep muscles from wasting due to atrophy and help keep good blood flow (Kluwer, 2011)

 Having pts repeat learned information helps the nurse determine what the pt learned (Alspaugh)

Pt stating why something is necessary helps determine their motivation to comply (Alspaugh)	

Goal not met: Breath sounds are not improved, still diminished with a respiratory rate of 20 breaths per minute, depth of 550 with a normal rhythm

Goals not met: pt wanted to spend time with family, no opportunity for teaching or exercises 	
	                     pts                                                    pts                                                                 pts                                                             pts

Reference(s): List all on back page or attach additional page. Use APA format.    
(pt)

Alspaugh, L. (n.d.). Health careers journal. Retrieved from http://www.healthcareersjournal.com/a-guide-for-nurses-teaching-healthcare-effectively-to-patients/
Crowe, J., & Bradley, C. (1996). he effectiveness of incentive spirometry with physical therapy for high-risk patients after coronary artery bypass surgery. Journal of the american physical therapy association, Retrieved from http://physicaltherapyjournal.com/content/77/3/260.full.pdf
Kluwer, W. (2011, December 12). Drugs.com. Retrieved from http://www.drugs.com/cg/active-range-of-motion-exercises.html
Morton, P., & Fontaine, D. (2009). Critical care nursing: A holistic approach. (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Porth, C. (2011). Essentials of pathophysiology. (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
(2012). Mosb'ys 2012 nursing drug reference. (25th ed.). St. Louis, MO: Elsevier Mosby.