Lakeview College of Nursing
Clinical Preparation Assignment
N210 
Student Name: Katey Goodpaster Date: October 23, 2011 Adm. Diagnosis: Atrial Flutter Allergies:Sulfa (Sufonamide antibiotics), wheat, flour, Maxiphen G, 													   Maxaquin, Ciprocinonide, Morphine, Gluten protein
                                                                                                                                                                                                                                        (5 pts)

Medical History: 

MI, Ulcerative colitis, CAD, thrombocytopenia, aortic valve disorder, diabetes mellitus type II, HTN, hyperlipidemia, pacemaker placement, renal disease, bladder cancer, CHF

Surgical History: 

AICO, prostatectomy, PR appendectomy, hernia repair, CABG, tonsillectomy, pacemaker placement, bladder surgery

Patient Initials:  BW Age: 83   Date of Admission: 10/18/11

Gender:   M     F    Ethnicity: Caucasian

Occupation: Self- Employed. Entrepreneur 
(Former work if retired)

Education: University of  Illinois graduate (Bachelors in business)

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

I live with my wife

Do I have any other family? Son, Daughter and grandchildren 

Adm. Date: 10/18/11 Adm. History: (What brought me to hospital?)			
   Patient drove himself to the hospital after having shortness of breath, chest pain and was experiencing a pounding sensation in his chest. 

I have had these procedures while I have been here: 

  Pacemaker placement 
 
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:

  Needs assistance getting out of bed, but able to walk, eat and do some hygiene on his own. 

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_______________________________    

         I am rating my pain as a    
       ________/10     I describe it as:
_____________________
__________________________________________

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	
4-11		
4.1	
RBC	
		
4.26	
K	
3.5-5.0		
4.6	
DIFF: 
Monocytes
Lymphocytes
Neutrophils
Eosiniphils
Basophils	

20-45
40-70		
5.2
5.2
88.9
.6
.1	
HGB

HCT			
13.6

40.7	
NA	
135-145		
141	
PT				
PLT	
140-400		
68	
CL	
101-111	
	
102	
INR				
APTT	
22.4-35.9		
79.1	
CA	
8.5-10.0	
7.8	
8.9	

GLUCOSE	
60-99		
129	A1-C				CO2			
30	

CHOLESTROL	
101-200		
201	
BUN	
6-20		
116	MG	
1.8-2.7		
2.1	

TRIGLYCERIDE				
CREATININE	
.1-1.20		
2.86	TSH			
2.28	

HDL/LDL
				BNP				OTHER				
OTHER
				OTHER				OTHER				
DIAGNOSTICS:  Test & Results                                                                                                                                                                     
   Chest X-Ray:                                                     Other: ECG 12 Lead – found left ventrical hypertrophy 
     
     EKG:                                                                Other:                                                                         Other:

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)

	Atrial Flutter

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

	With atrial flutter, the electrical currents of the heart take an unusual path through the atria, causing an increased heart rate pattern. When atrial flutter occurs, a patient’s heart rate is usually around 250-300 BPM (E-medicine health). Diseases of the heart and other areas of the body that change the rhythm and electrical current of the heart can cause atrial flutter.  Because this patient has a PMH of CAD, HTN, CHF, myocardial infarction, aortic valve disease, cancer and other diseases, the patient’s electrical current has been disrupted on multiple occasions. HTN, CHF, aortic valve disease and myocardial infarctions are the most common causes of atrial flutter. Some symptoms of atrial flutter are shortness of breath, chest pain and pounding in chest.

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)

	When the patient first came to the hospital, an ECG was orders. They were able to locate the time of arrhythmia that the patient was experiencing, atrial flutter. The PLT test showed that the platelets were low. This can be a result of his chronic renal disease or his ulceritis. The patient’s extremely high BUN and Creatinine levels are a result of the CKD due to his CHF or MI, etc. The patient’s cholesterol and glucose closely relate to type II diabetes. It can be a result of the different medications and insulin changing the glucose intake of the cells.

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 %:	BP:	Pulse:
Rate:
Rhythm:	Respirations:
Rate:
Rhythm:	Temp:

Route:	Pain:
Rating:         /10    Characteristics:          	Ht: _________
Wt: _________	
NEUROLOGICAL: 
 MAE:   Y        N           PERLA:    Y         N
Strength Equal:   Y      N   if no -   Legs   Arms    Both 
Orientation, Mental Status, Speech, Sensory, LOC, 	

	
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	

CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: _________
Neck Vein Distention:   Y   N      Edema  Y    N
Location of Edema____________________	 
	
RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character	

	
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:___________		
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: _________
Drains present:  Y         N       Type_______________		
EENT: 
Ears:                            Eyes:
Nose:                          Teeth:            

GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis   Y      N 
Inspection of genitals
Catheter:  Y    N      Type_____________	

	
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)	

USE THE BACK OF THE SHEET FOR ADDITIONAL SPACE FOR DETAILS. EXPECTATIONS MAY VARY FOR DIFFFERENT COURSES

Journal: Use additional pages as necessary							(5 pts)								
 Address the following questions as you reflect on your clinical experience.
1.	What was you planned schedule for the morning’s activities?
    (For example arrive 0630 to review medications & labs, 0700 get report, 0715 get vital signs & plan am care with patient)
2.	How accurate was your plan? Were there changes? If so Why were the changes necessary?
3.	What did you learn from your clinical experience today?  
4.	Did clinical practice today align with what was discussed in class and/or lab?    Elaborate.	                                                       
5.	If today could be repeated what would you do differently?
6.	Describe 2 ways you saw caring demonstrated today?
7.	Describe how you demonstrated or observed respect in the clinical setting.
8.	Do you have any concerns or questions related to clinical that you would like to reflect on or discuss?

				

Reference List for all references used in this document.    Use APA format.          			                 (1 pts)