Lakeview College of Nursing
Clinical Preparation Assignment
N210 
Student Name: Katey Goodpaster    Date: September 12, 2011 Adm. Diagnosis: Coronary Heart Disease (CAD) Allergies: Pentothal (Thiopental Sodium)
                                                                                                                                                                                                                                        (5 pts)

Patient Initials: __NM_____Age: _72____  Date of Admission:  8/31/11

Gender:   Male    Ethnicity: _____Caucasian______________________

Occupation: _Worked for a software company up until one month ago_
(Former work if retired)

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? _Children and Grandchildren (some of which with disabilities)____________________________________

Adm. Date: _8/31/11_______ Adm. History: (What brought me to hospital?)			
 Severe Chest Pain________________________________________

_________________________________________________________ 

_________________________________________________________

_________________________________________________________

I have had these procedures while I have been here: __Triple bypass surgery ___________________________________________________

__________________________________________________________

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: Very active up until about 1.5 months ago (walked and played tennis 3-4 times/week) Now, need help getting up and dressing, but can do most of hygiene on own.

Medical History: __No previous medical history except within the past month.__________________________

______________________________________________

______________________________________________

______________________________________________

______________________________________________

Surgical History: Triple bypass on 9/10/11______________________________

______________________________________________

______________________________________________

______________________________________________

______________________________________________

House

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    
       ____5____/10     I describe it as:
Slight chest pain (much better than previous days) Sore around incisions. _____________________
__________________________________________

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		9.72	9.72	RBC	4.10-5.7	3.47	3.47	K	3.6-5	3.5	3.5	
DIFF: 
Monocytes
Lymphocytes
Neutrophils
Eosiniphils
Basophils		

10.7
22.8
4.4
0.3	

10.7
22.8
4.4
0.3	
 HGB/

 HCT	
12-18%

37-51%	
10.7%

31.9%
	
10.7%

31.9%	
NA	
135-145	
137	
137	
PT		180	180	PLT		+1	+1	CL	101-111	104	104	
INR				APTT		30.9	30.9	CA	8.5-10.5	8.0	8.0	
GLUCOSE	70-105	149	149	A1-C				CO2	21-31	28.5	28.5	
CHOLESTROL				BUN	6-20	24	24	MG				
TRIGLYCERIDE				CREATININE		1.3	1.3	TSH				
HDL/LDL
				BNP				OTHER				
OTHER
				OTHER				OTHER				
DIAGNOSTICS:  Test & Results                                                                                                                                                                     
   Chest X-Ray:   
9/11 Poor Respiration effort with cardiomegaly
 9/12 Improvement since 9/11. Fluid in lower left chest                                                 Other: ECG 9/9                                                                        Other:
     
     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)

I will be identifying Coronary Heart Disease (CAD)

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).	

1.Simvastin (Zocor) oral 20 mg tablet daily with evening meal

2. Famotidine (Pepcid) oral tablet 20 mg daily

3. Chlorhexidine Gluconate (Peridex) .12% oral rinse 15mL two times daily.

 4.Heparin lock flush (Heparin) 100 unit/mL through IV every 12 hours

5.Aspirin 325 mg enteric coated tablet daily

6.Docusate Sodium (Colace) 100 mg capsule daily

	
1.Antihyper Lipidemic
HMG COA reductase inhibitor

2.Histamine H2- receptor inhibitor

3.Dental aids and preparations

4.Heparin

5.Analgesic/antipyretic salicylates 

6.lazatives and cathartics	
1.The arteries are blocked with fatty cholesterol, this drug helps reduce amount of fatty substances.

2. This drug is used to reduce heartburn. This patient has been having heart and chest pains for certain foods and drinks. This drug with help eliminate the pain.

3. This is used as mouthwash for proper dental hygiene. 

4.This drug is for blood thinning so that no blood clots are produced

5.This drug is to prevent further heart attack or stroke and to thin the blood to prevent blood clots.

6.The Simvastatin causes constipation, so this drug is used to reduce the constipation for the patient. 
	
1.Dark red urine, difficulty breathing or swallowing, weakness (fall risk)

2.Dizziness (fall precautions), Constipation, difficulty breathing or swallowing

3. Swelling of tongue, face or throat. Dizziness (fall risk)

4.Rapid change in blood pressure, unusual bleeding 		

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 %:
94%	BP:
98/72	Pulse:
Rate: 45
Rhythm: Faint	Respirations:
Rate: 14
Rhythm:
Normal	Temp:
99.3 F
Route: Oral	Pain:
Rating:       5  /10    Characteristics: Deep chronic pain in chest, soreness around incisions         	Ht: 6’.01”
Wt: 93.441 kg (206 lb)	
NEUROLOGICAL: 
 MAE:   Y        N           PERLA:    Y         N
Strength Equal:   Y      N   if no -   Legs   Arms    Both 
Orientation, Mental Status, Speech, Sensory, LOC, 	
Patient was able to have conversations, answer all of questions and recall past and present events. 
Speech  and mental status were very cognitive

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	
Difficulty with physical movement and activity so at a fall risk
Also, taking drugs that will cause dizziness and impairment that would cause a high risk for falling
He is able to do dental, face and hair hygiene, but needs help with overall bathing, gown changing and getting out of bed	
CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: _________
Neck Vein Distention:   Y   N      Edema  Y    N
Location of Edema____________________	 
S1 and S2 sounds audible
Capillary refill 3 seconds (slower than normal)
Edema around incision on right radial area.	
RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character	
Respiration rhythm and rate normal

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:___________	
Diabetic diet at home and currently 
On a 500 mL/day fluid restriction (including IV)
Has lost appetite within the last 48 hours
Incision on right radial area and incision scar on left radial area
No ostomy, nasogastric or feeding tubes	
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: _________
Drains present:  Y         N       Type_______________	
Skin and nails appropriate to ethnicity
Bruising near right radial incision	
EENT: 
Ears:                            Eyes:
Nose:                          Teeth:            
                             	
EENT – normal
Keeps up with hygiene well	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis   Y      N 
Inspection of genitals
Catheter:  Y    N      Type_____________	
Urine color light yellow
Output is appropriate with amount of intake (including IV)
No catheter
	
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)	
No college experience
Previously worked at a Software Company until about 1.5 months ago when it closed down
Lives with wife at home (whom is very supportive)
Walks and plays tennis with wife 3-4 times/week
Because he was very active before, he is having a hard time coping with having to be in the hospital and inactive for such a long period of time
Very family orientated – close with children and grandchildren