Lakeview College of Nursing
Clinical Preparation Assignment
N210 
Student Name: Katey Goodpaster Date: 10/2/2011 Adm. Diagnosis: Congestive Heart Failure Allergies :Diovan, Actos, Florinef, Sulfa (Sulfonsmide antibiotics)
                                                                                                                                                                                                                                        (5 pts)

Patient Initials: SC Age: 72  Date of Admission: 10/2/2011

Gender:   M     F    Ethnicity: Caucasian 

Occupation: Retired, but worked a desk job at a Microsoft company
(Former work if retired)

Education: High school – graduated in 1957

Where do I live?  House     Farm     Apt.    Asst. Living    (circle one)
                             
             Nursing Home   Other_______________________

I live with husband

Do I have any other family? Children and grandchildren, but all live out of state.

Adm. Date: 10/2/2011 Adm. History: (What brought me to hospital?)			
 Husband brought patient to hospital very early on October 2, because patient was complaining of deep and sharp chest pain.

I have had these procedures while I have been here: 

CABG, catheter 

I need help with:   Hygiene      Moving        Eating       Dressing

I need help:         Not at All        Some           Lots             Totally

I have a     DNR       POA       Living Will       None

Activity Level: Once patient is helped out of bed and prosthetic is on, patient can stand and pivot to chair. Can walk short distances with PT, but becomes out of breath quickly

Medical History: Morbid obesity, OSA, HTN, hyperlipidemia, triple vessel, CAD, a fib, diabetes, mellitus, CKD, breast cancer, arthritis, cellulitis left hand

Surgical History: Hysterectomy, dental, colonoscopy, mastectomy, PTCA stent, coronary artery bypass graft, left leg amputation, right toe amputate, ash catheter incision.

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

Incentive Spirometer     Foley    NG     IV 

  Cast   Splint    Drain     Telemetry     Oxygen

 Chest Tube    Trach      Ostomy       Dressing

TED/SCS      Walker/Crutches      Wheelchair

Other: Prosthetic (Left leg)    

         I am rating my pain as a    
       ____0____/10     I describe it as:
No pain

All data is collected and is recorded using the appropriate terminology.  All sections are complete. 
Any data that is not collected is adequately explained in the blank spaces ie NA or unavailable. 

LAB DATA (List all pertinent/current lab/diagnostic values and highlight which one(s) are abnormal)      			  (1pts)                                                                               
TEST	NORMS	BEFORE	NOW	TEST	NORMS 	BEFORE	NO W	TEST	NORMS	BEFORE	NOW	
WBC			
8.34	RBC	
3.5-5.2		
3.8	K	
3.6-5.0		
4.7	
DIFF: 
Monocytes
Lymphocytes
Neutrophils
Eosiniphils
Basophils			
12.6
23.7
59.8
3.8
0.1	
HGB

 HCT	
12-18

37-51		
11.5

37.3	
NA	
135-145		
141	
PT			
NA	PLT			
213	CL	101-111		
108	
INR			
NA	APTT			
45.2	CA	8.5-10.5		
8.7	

GLUCOSE	
90-120		
83	A1-C			
NA	CO2	21-31		
27.3	

CHOLESTROL	
<200		
251	
BUN	
6-20	
	
34	MG			
NA	
TRIGLYCERIDE			
281	CREATININE			
1.61	TSH			
NA	
HDL/LDL
			
38	BNP			
NA	OTHER				
OTHER
				OTHER				OTHER				
DIAGNOSTICS:  Test & Results                                                                                                                                                                     
   Chest X-Ray: lung volume low, cardiac silhouette enlarges                                           ECG: 9/2 chest pain
     
     EKG:                                                                Other:                                                              9/3 tachycardia

PATHOPHYSIOLOGY:  4 parts, answer all 4 questions in a thorough manner using own words and appropriate medical terminology, use additional paper if necessary.

1. Identify the primary disease(s) that will be explained in this paper.     (1pt)
	
Congested Heart Failure (CHF)

2. Describe the pathology of this disease; include any causative factors/etiologies that can be identified.     (5 pts)

3. Relate the abnormal labs and diagnostics to the disease process.  If all tests are WNL then indicate which values 
    are important to monitor and explain why.       (3 pts)

4. Relate the medications to the disease process or patient situation; include any precautions to be aware of when administering.        (3 pts)

MEDICATIONS:                                                                                                                                                                               (6 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.
Include PRN meds only if they are administered during clinical time. 
Name, prescribed dose and frequency; plus usual dose and frequency of administration. 	Classification & mechanism of action. [Use your drug reference]	Why is medication ordered for THIS patient?	 Nursing Precautions/ Considerations needed to safely administer this medication. 	 Evaluate medication effectiveness for THIS patient (patient response).	

					

Priority Nursing Diagnosis:															                  (2pts)
(Use NANDA format)	
														
What does the patient/client need to accomplish?
GOALS/OUTCOMES

Measurable patient centered goals 
are identified realistic and contain 
time element.  	What can the nurse do to help resolve the problem?
IMPLEMENTATION
Nursing Interventions

Specific nursing actions can easily be linked to the outcomes.  The interventions are realistic and appropriate to the patient's current status.	Why will the nurse do these actions?

SCIENTIFIC RATIONALE
Be sure to include source using APA format

Rationales for each intervention contain comprehensive scientific reasoning that succinctly identifies why the intervention was selected.  Citation is provided.	How did the patient/family respond to the nurse’s actions? 
EVALUATION
Client Response 

Includes all the following: 1.Client’s response to the intervention(s),
 2. Status of goals and outcomes, (ie goal met, in progress or revised) 3. Modifications to the plan of care.	

				
	                             (2pts)                                                                    (2 pts)                                                                                (2 pts)                                                                                    (2 pts)

PHYSICAL ASSESSMENT DATA (collect own data on clinical day)     (Use Taylor Chapter 25 & N201 materials as resources)              (5 pts)
All subjective & objective data is collected and recorded using appropriate terminology. Data not collected or requiring elaboration is explained in the blank spaces.  
Pulse Ox %:
82	BP:
96/58	Pulse:
Rate: 82
Rhythm: At times would get into the 140’s	Respirations:
Rate: 20
Rhythm:	Temp:
98.1
Route:
oral	Pain:
Rating:    0     /10    Characteristics:          	Ht: 1.49 M (4’11”)
Wt:102.3kg (225 lb)	
NEUROLOGICAL: 
 MAE:   Y        N           PERLA:    Y         N
Strength Equal:   Y      N   if no -   Legs   Arms    Both 
Orientation, Mental Status, Speech, Sensory, LOC, 	
Not equal bilaterally with legs – Right leg prosthetic 
Equally bilateral with arms

MUSCULOSKELETAL: 
Neurovascular status, ROM, Supportive devices/strength

ADL Assistance    Y   N       Fall Risk:    Y   N
Fall Score______________
Activity/Mobility Status:    Independent (up ad lib)     
            Needs assistance with equipment   
            Needs support to stand and walk	
3 assists needed
High risk fall patient
Prosthetic RL	
CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: _________
Neck Vein Distention:   Y   N      Edema  Y    N
Location of Edema____________________	 
Random spurts of tachycardia at resting (into the 140’s)
But normally slightly low	
RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character	
On oxygen (3mm)

GASTROINTESTINAL:
Diet at home :                 Current Diet:   

Auscultation: Bowel sounds, other sounds
Last BM, character &  freq of stools 
Palpation: Pain, Mass etc
Inspection: distention, incisions, scars, drains, wounds
Ostomy:    Y       N         Nasogastric:    Y      N  
Feeding tubes/PEG tube   Y      N      Type:___________	
On cardiac diabetic diet 
No salt added
2 BM (loose and brown) in last 24 hours
	
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: _________
Drains present:  Y         N       Type_______________	
Relative with ethnicity
No wound drainage, bruising or turgor
Slight pink rash on left posterior thigh	
EENT: 
Ears:                            Eyes:
Nose:                          Teeth:            
                             	
Has dentures and glasses
No excessive discharge from nose or ears	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis   Y      N 
Inspection of genitals
Catheter:  Y    N      Type_____________	
Output relative to input
Dark yellow in color with slight odor

PSYCHOSOCIAL/CULTURAL:
Educational level

Developmental level       

Coping methods          

Health Beliefs
Occupation (previous if retired)

Religion & what it means to pt.
Personal/Family Data    (Think about home environment, family structure, and available family support)	

Has a high school degree
Has lived in Champaign area whole life
Lives in a house with her husband
All other family is in far distance from them
Doesn’t smoke or drink (but used to smoke two packs a day), but quit over 30 years ago

		

Journal

     1. Schedule
0630 arrive and review patient’s data
0700 get report
0715 introduction and interview
0745 Clean dentures, face and hands for breakfast, then leave patient to eat
0830 return to continue interview
0900 take vital signs
0920 start with morning hygiene 
1000 Sit patient in chair with TED and change linens while finishing interview
1035 Leave patient for nap
1115 check blood glucose level before lunch 
1130 Ask any additional questions and say goodbyes
	2. For the most part, my schedule stayed on track. The patient had an unplanned ECG in the morning because of tachycardia earlier that morning, so I had to work around that. Also, PT and morning blood work always needs to be worked around because you do not always know exactly when they are coming or when they will get to your patient. 
	3. Today, I learned how to pass medications to a patient and how to put on a prosthetic leg. I thought it was extremely interesting that I was able to have these experiences in the clinical setting.
	4. Yes, the medication amounts and doing the “three-step check” aligned with what we are learning about in lecture and lab. Passing medications to an actual patient shows you how important it is to check the medications and amounts multiple times. 
	5. If today could be repeated, I would try to spend more time with my patient. The patient had visits from doctors, cardiologists, family members and physical therapists, so it was hard for me to be in there for long periods of time.
	6. Today I saw caring when the hospital sends a rose to each patient to make them feel cared for. My patient told me she knew that every patient received one, but that it still seemed personalized. I also saw caring by one of the nurses. There was a patient in isolation and each time she was going to enter the room, she put her head in the door so that the patient recognized her face before she got fully gowned. 
	7. I think I demonstrated respect while giving my patient her shower. I make an effort to tell her each step I am doing before I do it so that the patient is not surprised by anything. I always ask the patient if she would like to wash their own genitals or for me to do it for them so that the option is there for them.

Reference

Lippincott, Williams, Wilkins (2008). CABG nursing diagnosis. Handbook of Nursing Diagnosis. Woltens 		 Kluwer health