Student Nurse: Jeanine Diaz Cedar Crest College

Clinical Date: 7/8/16 Course: 309_____

Clinical Site: St. Lukes Quakertown Clinical Preparation

Demographics Reason for Hospitalization

S Date of Admission: 7/6/16 Allergies: Codeine, Epinephrine Hcl Chief Complaint: Fever of 101, weakness, generalized, poor
appetite for several days, legs gave out while using walker and
Code Status: Level 3 DNR Initials: MM 88 year old female assisted to floor.

Admitting Physician: Erin Fly, DO HPI: Fever 101, generalized weakness and presented to ER
with UTI. Significant history of CVA felt to be embolic from
Consulting Physicians: Francis Burt, MD her A. Fib in Feb. Has been fairly stable since. Gets up 2 to 3
times a night to urinate but denies any burning.
Other Disciplines/Therapies involved in Client care:
Physical Therapist Admitting Diagnosis: UTI/Sepsis

Define Medical Diagnosis: UTI: An infection in the normally

sterile urinary tract system. P. 1619 Sepsis: Systemic infection
P. 1615

Date & Type of Surgery/Procedure:

PMH/PSH /Chronic Conditions (use other side if Significant abnormal Trending of Lab Inference of Abnormal Values
B needed) Labs Values
PMH/PSH/CC: PMH: Stroke due to embolism of
_CBC and Differential- Increasing and
middle cerebral artery, GERD, Glaucoma Urinary tract infection
WBC 11.76 (H), decreasing
(Chronic) Atrial Fibrillation, Periorbital contusion Platelet 114 (L)
PSH: none
CC: Fever 101, poor appetite, and generalized Comprehensive
weakness metabolic panel- Decreasing and Urinary tract infection
chloride 97 (L), increasing
Alkaline phosphatase
125 (H), Bilirubin 1.20
(H)
Definitions: GERD: An upper gastrointestinal
disease caused by the backward flow of Lactic acid, plasma- 2.6
Sepsis
gastrointestinal continents into the esophagus. (H) Increasing
Glaucoma: Eye disease resulting in increased
intraocular pressure, causing reduced blood flow Urinalysis w/ culture-
to the optic nerve and retina and followed by leukocytes, UA large Urinary tract infection
tissue damage. (A), Blood, UA small
Atrial Fibrillation: A cardiac dysrhythmia in (A)
which multiple rapid impulses from any atrial
Urine microscopic-
foci, at a rate of 350 to 600 times per minute, RBC, UA 1-2(A),
Urinary tract infection
depolarize the atria in a totally disorganized WBC, UA innumerable
manner, with no P waves, no atrial contractions, a (A), Bacteria
loss of the atrial kick, and an irregular ventricular innumerable (A)
response.

Diagnostic Procedures (ex. X-ray, Ultra Sound, CT Scan, EKG) Results Procedure Prep or Post Care
B 1. ECG – Atrial fibrillation poor anterior R wave progression is noted, abnormal ECG
2. _____________________________________________________________________________________________________________
3. ______________________________________________________________________________________________________________
4. ______________________________________________________________________________________________________________
5. ______________________________________________________________________________________________________________
6_______________________________________________________________________________________________________________

Medication Dose/Route/Time Drug Classification Reason client Taking Major Side Effects Associated Labs
B Acetaminophen
(Tylenol)
650mg/PO/once Ther. Class.
antipyretics
Fever GI: HEPATOTOXICIT
Y (↑ DOSES)
valuate hepatic,
hematologic, and

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Student Nurse: Jeanine Diaz Cedar Crest College
Clinical Date: 7/8/16 Course: 309_____
Clinical Site: St. Lukes Quakertown Clinical Preparation

nonopioid ACUTE renal function

analgesics GENERALIZED periodically during
EXANTHEMATOUS prolonged, high-
PUSTULOSIS, STEVE dose therapy
NS-JOHNSON
SYNDROME, TOXIC
EPIDERMAL
NECROLYSIS
apixaban 5mg/PO/BID Ther. Class. Decrease risk for Bleeding
(ELLQUIS) anticoagulants stroke
Pharm. Class.
factor xa inhibitors

Atorvastatin 80mg/PO/daily Ther. Class. Decrease risk for MS: RHABDOMYOL Evaluate serum
(LIPITOR) lipid-lowering stroke YSIS cholesterol and
agents ANGIONEUROTIC triglyceride levels
Pharm. Class. EDEMA before initiating,
hmg coa reductase after 2–4 wk of
inhibitors therapy, and
periodically
thereafter.
Calcium carbonate 750mg/PO/HS Ther. Class. GERD arrhythmias Monitor serum
(TUMS) mineral and calcium or ionized
electrolyte calcium, chloride,
replacements/supple sodium, potassium,
ments magnesium,
albumin, and
parathyroid
hormone (PTH)
concentrations
before and
periodically during
therapy for
treatment of
hypocalcemia.
Cefepime 500mg in Ther. Class. UTI CNS: SEIZURES May cause
(MAXIPIME) dextrose 5% anti-infectives GI: CLOSTRIDIUM positive results for
50ml/IVPB Q DIFFICILE- Coombs' test in
Pharm. Class.
patients receiving
12H fourth generation ASSOCIATED
high doses or in
cephalosporins DIARRHEA (CDAD) neonates whose
ANAPHYLAXIS mothers were
given
cephalosporins
before delivery.
May cause ↑ serum
AST, ALT,
bilirubin, BUN,
and creatinine.
May rarely cause
leukopenia,
neutropenia,
thrombocytopenia,
and eosinophilia.

Docusate sodium 100mg/po/bid Ther. Class. Prevent constipation

(COLACE) laxatives
Pharm. Class.
stool softeners
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Student Nurse: Jeanine Diaz Cedar Crest College
Clinical Date: 7/8/16 Course: 309_____
Clinical Site: St. Lukes Quakertown Clinical Preparation

Escitalopram 10mg/po/daily Ther. Class. Anxiety/depression NEUROLEPTIC

(LEXAPRO) antidepressants MALIGNANT
Pharm. Class. SYNDROME, SUICID
selective serotonin AL THOUGHTS
reuptake inhibitors SEROTONIN
ssris SYNDROME

Latanoprost 0.005% Not in Davis Drug Glaucoma?

(XALATAN) ophthalmic Guide
solotion/1
drop/both
eyes/HS
Levofloxacin 250mg/IVPB Ther. Class. UTI ELEVATED ↑ serum AST,
(LEVAQUIN) Q24H anti-infectives INTRACRANIAL ALT, LDH,
PRESSURE (INCLUDI bilirubin, and
Pharm. Class.
alkaline
fluoroquinolones NG PSEUDOTUMOR
phosphatase.
CEREBRI),SEIZURES, May also cause ↑
HEPATOTOXICITY, or ↓ serum
CLOSTRIDIUM glucose.
DIFFICILE-
ASSOCIATED
DIARRHEA STEVEN
S-JOHNSON
SYNDROME,ANAPH
YLAXIS
Metoprolol 25mg/PO/daily Ther. Class. Ventricular BRADYCARDIA, HF,
succinate arrhythmias PULMONARY May cause ↑ BUN,
antianginals
(TOPROL-XL) EDEMA serum lipoprotein,
antihypertensives potassium,
Pharm. Class. triglyceride, and
beta blockers uric acid levels.
May cause ↑
ANA titers.
May cause ↑ in
blood glucose
levels.
May cause ↑
serum alkaline
phosphatase,
LDH, AST,
and ALT
levels.

List medication patient takes at home: apixaban, atorvastatin, docusate sodium, escitalopram, lorazepam, succinate, potassium
chloride, torsemide, calcium carbonate, latanoprost, multiple vitamin, psyllium

Vital Signs Day of Prep Day of Care Vital Signs Day of Prep Day of Care
A Temp 98.4 98.1 BP 124/57 128/56
No pain
HR 72 60 Pain No pain
RR 17 18 O2/Pulse OX 94% room air 94% room air

Indicate Rationale
A IV sol, rate, site
Diet
Left forearm hep-lock
Regular
Tube Feeding Ø
Activity Order Bedrest/ bathroom privilege Patient is high risk for fall due to weakness in lower extremities and no balance
PT Ø
TEDS/SCD Ø

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Student Nurse: Jeanine Diaz Cedar Crest College
Clinical Date: 7/8/16 Course: 309_____
Clinical Site: St. Lukes Quakertown Clinical Preparation

Finger Stick Blood Sugars Ø

ASSESSMENT Day of Prep Day of Care ASSESSMENT Day of Prep Day of Care
A NEUMAN SYSTEMS VARIABLES Activity/Gait

Nervous/anxio Equipment/ CPM/Traction Ø Ø

1. PSYCHOLOGICAL
us Nervous/anxious Walker/cane/crutches walker walker

Integrity vs. Integrity vs. Pulmonary

2. DEVELOPMENTAL
despair despair O2 amt/delivery mode Ø Ø

Good family Good family O2 saturation 94% 94% room air

3. SOCIOCULTURAL
support support Respiratory effort Ø Not labored
Crackles:
expiratory Crackles in
4. SPIRITUAL Lung sounds wheezes right lower lobe
unknown Christian Cough/Secretions Ø absent
5. PHYSIOLOGICAL Chest Tubes Ø Ø
CARDIO GI
Irregularly-
Heart Sounds: rate & rhythm Ø irregular Abdomen
Pulses: peripheral & apical Ø 60 BPM Bowel sounds, tenderness, Distention? Ø Not assessed
1+/4 right and
right lower 2+/4 left lower Improved/ 90%
Edema extremity extremities Appetite/% eaten poor of meals eaten
Capillary Refill sluggish sluggish/>3 sec. Nausea/vomiting Ø Ø
Jugular Vein Distention Ø absent Tube feeding: type/site Ø Ø
Skin Other tubes/drains Ø Ø
Color/Temp Ø Pale/warm GU
Decreased
turgor/tenting/ext
Turgor/Moisture ernal moist Urine description
Mucous Membranes Ø pink Catheter Ø
IV site Left forearm Left forearm Bladder scan Ø
Braden score/stage INTAKE
NEURO Type Amt Not assessed Not assessed
LOC Ø Ø
Orientation A&O x3 A&O x3 OUTPUT
Follows commands Yes Yes Type Amt Urine/200ml Not assessed
Stool/ 1
Last BM _7/7/16_______ formed,
PERRLA Ø PERRLA Description & frequency of stools medium Ø
Swallow/Speech clear clear Safety Issues
Musc-Skeletal Restraints no no
2+/5 Left
extremities 3+/5
Extremity Strength decreased right extremities Fall precautions yes yes
LUE/limited LUE/limited Yes- right ear Right and left
Movement/ Sensation LLE/limited LLE/limited HOH and left ear ear
Moderate Moderate
ROM Ø Ø Vision impaired impaired
Other Fall Score Ø 85

Dressings & Wound Care Plan of Care (Your Concept Map)

R See concept map

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Student Nurse: Jeanine Diaz Cedar Crest College
Clinical Date: 7/8/16 Course: 309_____
Clinical Site: St. Lukes Quakertown Clinical Preparation

Other Treatments (ex. Chest tubes, feeding tubes) Teaching Goals : Educate patient on importance to call for assistance
None with activity to prevent falls and injuries.

Discharge Plan:

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Student Nurse: Jeanine Diaz Cedar Crest College
Clinical Date: 7/8/16 Course: 309_____
Clinical Site: St. Lukes Quakertown Clinical Preparation

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Student Nurse: Jeanine Diaz Cedar Crest College
Clinical Date: 7/8/16 Course: 309_____
Clinical Site: St. Lukes Quakertown Clinical Preparation

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Student Nurse: Jeanine Diaz Cedar Crest College
Clinical Date: 7/8/16 Course: 309_____
Clinical Site: St. Lukes Quakertown Clinical Preparation

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Student Nurse: Jeanine Diaz Cedar Crest College
Clinical Date: 7/8/16 Course: 309_____
Clinical Site: St. Lukes Quakertown Clinical Preparation

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Student Nurse: Jeanine Diaz Cedar Crest College
Clinical Date: 7/8/16 Course: 309_____
Clinical Site: St. Lukes Quakertown Clinical Preparation

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Student Nurse: Jeanine Diaz Cedar Crest College
Clinical Date: 7/8/16 Course: 309_____
Clinical Site: St. Lukes Quakertown Clinical Preparation

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Student Nurse: Jeanine Diaz Cedar Crest College
Clinical Date: 7/8/16 Course: 309_____
Clinical Site: St. Lukes Quakertown Clinical Preparation

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Student Nurse: Jeanine Diaz Cedar Crest College
Clinical Date: 7/8/16 Course: 309_____
Clinical Site: St. Lukes Quakertown Clinical Preparation

References

Doenges, M. E., Morrhouse, M. F., & Murr, A. C. (2016). Nursing Diagnosis Manual (5th ed.). Philadelphia,

PA: F. A. Davis Company.

Deglin, J. H., Vallerand, A. H., & Sanoski, C. A. (2011). Davis's drug guide for nurses. Philadelphia: F.A.
Davis.

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Student Nurse: Jeanine Diaz Cedar Crest College
Clinical Date: 7/8/16 Course: 309_____
Clinical Site: St. Lukes Quakertown Clinical Preparation

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