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    
       ___0_____/10     I describe it as:
None________________
__________________________________________

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	
165	
141	
PT				
PLT	
140-400		
68	
CL	
101-111	
123
	
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)

	Most of the medications directly relate to controlling the patient’s atrial flutter. All of the other medications directly relate to past or reoccurring diseases, such as: Type II diabetes, hypertension, ulcerative colitis, etc. Many of the medications are vital to proper electrolyte upkeep and maintenance and for proper organ and body functions. The patient is not on many pain medications, but the ones that are being taken are effective because the patient is not experiencing any pains. 

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).	

1.Allopurinol 100 mg daily

2.Acetaminophen (Tylenol) 650 mg 2 times daily every 4 hours

3. Amiodarone (Codarone, Pacerone) 400 mg x2 twice daily

4. Balsalazide (Colazal) 2250 mg 3 times daily

5. Calcium citrate – Vitamin D3 250 mg 2 times daily

7. Digoxin  (Lanoxin) .125 mg every other day

8. Furosemide (Lasix) 40 mg BID

9. Heparin IV 1.9 mL PRN

10. Insulin Aspart (Novolog) sliding scale 4 times daily

11. Isosorbide dinitrate 10 mg BID

12. Omeprazole (Prilosec) daily before breakfast

13. Ondansetron 

14. Warfarin (Coumadin) 5 mg	
1.Hyperuricemia TX – xanthine oxidose inhibitor

2.Analgesic 

3.Antiarrhythmics 

4.TX – chronic inflammatory

5. Calcium replacement

7. Digitalis glycosides

8.Loop diuretic

9. Heparin

10. Insulins

11. Vasodilators

12. Proton – pump inhibitors

13. Antivertigo

14. Anticoagulants	
1.Carenal Calculus

2. Pain

3. Atrial arrhythmia 

4. Ulcerative colitis 

5. Increases Ca levels

7. Atrial arrhythmia

8.Decrease in Na and Cl

9. A-fib

10. Type II Diabetes

11. Angina, heart pain

12. Ulcer disease

13. Nausea, vomiting

14. A-fib	
1.Renal failure

2. Nausea/ Vomiting

3. Hypotension, Bradyarrhythmia

4. Nausea, vomiting

5. Dehydration

7. Thrombocytopenia

8.Hyperuricemia

9.Thrombocytopenia

10. Hypoglycemia/ hypokalemia

11. Dizziness

12. Diarrhea, Nausea

13. Constipation, A-fib

14. Tissue Necrosis	
1.Effective, 

2. Effective, patient is experiencing no pain

3. Slightly effective, pt is still experiencing arrhythmias

4.  Effective, no inflammation or pain

5. Effective, Calcium levels have reached levels within normal range

7. Effective, atrial arrhythmias decreased

8. Effective, Na and Cl levels are now within normal range

9.  Effective, A-fib controlled

10. Effective, glucose levels decreased

11. Effective, pt is experiencing no pain

12. Effective, no more GERD occurring

13. Effective, no nausea or vomiting

14. Effective, A-fib controlled	

Priority Nursing Diagnosis: Altered tissue perfusion r/t the amount of blood the tissues receive with evidence by poor circulation and arrhythmias due to atrial flutter.						(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.	

Decrease risk of altered tissue perfusions by increasing oxygenated blood circulation throughout the body. 

	

Body massage patient to increase proper oxygenated blood flow. Make sure proper arrhythmia medication is being taken.	

By massaging different areas of the body, the blood flow will increase, allowing the patient’s vital organs and tissues to receive the nutrition and oxygen needed. The arrhythmia medications will decrease the abnormal beats of the heart and allow better blood flow throughout the body.	

The patient is willing to allow nurse to give body massages and for them to cooperate with all medications in order to decrease the risk of proper tissue profusion. The goal is still in progress. The goal is continuous, but expected to last for the remainder of hospital stay. If patient does develop an altered tissue perfusion, medication and massage modifications with me made.	
	                             (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 %:
       95	BP:
176/99	Pulse:
Rate: 75
Rhythm:	Respirations:
Rate:19
Rhythm: RRR	Temp:
97.5 F
Route: Oral	Pain:
Rating:     0    /10    Characteristics:          	Ht: 1.702m (5’7”)
Wt: 77 kg (169 lb)	
NEUROLOGICAL: 
 MAE:   Y        N           PERLA:    Y         N
Strength Equal:   Y      N   if no -   Legs   Arms    Both 
Orientation, Mental Status, Speech, Sensory, LOC, 	Pt. is oriented with alert mental status 

Speech is not delayed and is able to response to questions with correct answers

Senses equally bilaterally 	
MUSCULOSKELETAL: 
Neurovascular status, ROM, Supportive devices/strength

ADL Assistance    Y   N       Fall Risk:    Y   N
Fall Score____53__________
Activity/Mobility Status:    Independent (up ad lib)     
            Needs assistance with equipment   
            Needs support to stand and walk	

Needs assistance sitting up and getting out of  bed, but once up pt can walk on own without any assistance for support

Neurovascular status is equal bilaterally 
	
CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: _4_sec_______
Neck Vein Distention:   Y   N      Edema  Y    N
Location of Edema____________________	 
Atrial Flutter – Active pacemaker installed	
RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character	
Respiratory RRR

No crackles	
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:___________	
Gluten-free, Diabetic diet

Average of 4 BM’s a week

No pain, masses or enlarged organs palpated

Ostomy bag in place
	
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: ____4_____
Drains present:  Y         N       Type_______________	
Bruising present on left arm, near old IV site
Large rash on L tibial
Skin very dry and crackled 	
EENT: 
Ears:                            Eyes:
Nose:                          Teeth:            
                             	
Dentures, glasses, hearing aid, nasal drainage	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis   Y      N 
Inspection of genitals
Catheter:  Y    N      Type_____________	
Previously had bladder cancer
Has an ostomy bag
Urine is cloudy and foul smelling
	
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)	

Graduated from U of I with a business degree

Became an entrepreneur – invented the sled that attaches onto tractors

Very family orientated. Close with wife, 2 kids and grandchildren. They all live in the same area. Helps with health coping methods. Wife is handicapped and unable to assist in many of pt’s daily activities

Methodist – very religious 

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

Journal

     1. Schedule
0630 arrive and review patient’s data
0700 get report
0715 introduction and interview
0745 Clean teeth, face and hands 
0830 return to continue interview
0900 take vital signs
0920 start with morning hygiene 
1000 Leave patient for nap
1045 Continue with interview questions
1115 Ask any additional questions and say goodbyes
2. My schedule was on track for the most part. The patient’s breakfast came late, and they did not want to start hygiene until afterwards. So, the bathing got pushed back a little later than anticipated. I got to have a lot of time with the patient to interview and get to know the patient. I connected and got to know the patient the most out of any other clinical patients so far.
5. This week’s clinical was by far my favorite, most interesting and best learning experience possible. Not only did my patient and I connect well, but I got to see very interesting and new things that I have never seen before. If today could be changed, I would have gotten to know the patient a little better, even though I got to know the pt very well, but there is not much I would change about the day.
6. Today I saw caring demonstrated by another patient in the hallway. This patient was a lot more mobile than the patient walking passed him with three other assists. The more mobile patient was encouraging the assisted patient. I also saw caring being demonstrated by a nurse to another nurse. One nurse is pregnant and was dealing with a nauseous patient and it was making her nauseous. The other nurse took care of her patient for her so that she did not have to experience vertigo.
7. I saw respect being demonstrated by my nurse. Every learning process that was available, he would come and make it a point to teach me important tasks. He constantly reminded me about how he used to be in the same place, and wanted us to have a great learning experience. Also, he would give me the chance to perform tasks learned in labs and lectures; start piggybacks, give insulin etc.

References

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

				

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