YOUNGSTOWN STATE UNIVERSITY Date of Care: 10-24-2019

Department of Nursing Nurse’s Name: Sydney

Nursing 4840L Clinical Data Base ____

Student Name: Jenna Matheny Date Admitted: 10-22-2019 Height: 5’11

Pt’s Initials: DN DNR Status: Full Code Weight: 172lb
Room #: 12___NSIC Isolation Type: None Upon admission
Age: 57 y.o. Allergies: Contrast iodides, sertraline, tetracyclines
Sex: Female Percocet, shell-fish derived products,
Ultram, Zoloft, Wellbutrin

Diagnosis (es): ____communicating hydrocephalus____

Reason for Admission/Events Leading to Current Hospitalization:

(include reason patient is still in Unit >2 days if appropriate)

Patient was brought to the ED after her family noticed her complaining of some headaches followed by altered
mental status and not eating or drinking well. 10-22-2019 pt. had altered mental status. A CAT scan was done
and showed communicating hydrocephalus. Pt. was following commands, talking, and alert at this time. 10-23-
2019  RRT for lethargy and brought to NSIC. Pt. was supposed to be taken to UPMC via life-flight but was
cancelled due to the RRT. The reason for the RRT was because patient was desaturating, chest not rising. She
was pronounced brain dead, pupils are blown, no corneal reflex, no gag, doesn’t move to painful stimuli, no
reflexes, not breathing over vent. 10-24-2019 Life Bank is on the patient’s case, currently waiting for family to
make further decisions.

Pertinent History if Illnesses/Surgery:

History of alpha-1 antitrypsin deficiency, DVT, COPD, peptic ulcer disease, acute respiratory failure, aneurysm
(repaired at UPMC), arthritis, deafness. Encounter for pre-transplant evaluation for lung transplant, legionella
pneumonia, Prinzmetal angina, PE, vertigo
Surgical History: back surgery, cardiac surgery, endoscopy of colon (2017), brain aneurysm clipping

Day of Care (ranges): Vent Settings:

T 97.6 – 97.7 ETT (size/lip-line): 21
BP 103/61 – 126/86 Vent: Mode: Assist control
MAP 108 Rate: 14
HR 96 - 104 FiO2: 50%
RR 14 TV: 450 10-24-2019 2:30 am
SpO2 97-99 PEEP: 5 Right frontal external
ventricular drain
Oxygenation (select all that apply) (ventriculostomy)
N/C____Liters CVP______ done at bedside
CPAP____ BiPAP_____ Arterial Line______

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Physical Assessment: Day of Care

Neurological:
LOC: unresponsive Orientation: intubated/unresponsive Ordered Sedation: none
Opens Eyes: no GSC: 3T Pupils: blown, round, nonreactive
Speech: intubated Tongue: midline, pink, dry Face Symmetry: yes

Cardiovascular:
Rhythm: sinus tachycardia Pulse: regular/irregular Pacemaker: no
JVD: no Cap Refill: (<sec/>sec) Heart Sounds: S1 and S2

Peripheral Vascular:
Pulses: (Palp or Doppler) Radial: R +2 L +2 Pedal: R +2 L +2 Post Tibial: R +2 L +2
Edema: Yes/No Location: ___________________

Respiratory:
Breath Sounds: diminished throughout Sputum: no
Chest Tubes: No Cough: Y/N (productive/nonproductive)

GI:
Diet: NPO NG Suction Drainage: _______ Stool: Y/N
TPN: ______ Abdomen: soft, rounded FMS: _______
TF (type/rate):_____ Bowel sounds: active x4 quadrants Incontinent: Y/N
NG/OG/PEG/FT (circle) Ostomy (type): none Color/Character: ______
Waiting for NG tube order  Tube feed and H2O flushes are ordered

GU:
Urine: Color pale yellow Clarity: clear Amount:_____ Catheter: Foley
Genital Irritation: no Dialysis:______

Skin:
Temperature: warm, dry Color: appropriate for ethnicity Turgor: good elasticity
Mucous membranes: dry Incisions: right posterior ventriculostomy
Wounds: ______

Musculoskeletal:

Upper Extremities (passive ROM with this patient)

Movement: no movement Strength: cannot hold against gravity Sensation: no response to painful stimuli

Lower Extremities (passive ROM with this patient)

Movement: no movement Strength: cannot hold against gravity Sensation: no response to painful stimuli

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Continuous IV Drips: IV Drips must also be looked up and included on Med Sheet

Medication Concentration Rate Site Line

0.9% sodium 125 mL/hr Right antecubital Peripheral
chloride
Levophed 16 mg in dextrose 1.9 mL/hr Right antecubital Peripheral
5% 250mL

Intake/Output/Weight:

24 hour Intake: 318 24 hour Output: 1,294 Cumulative Fluid Balance (prior day): -976
6 hour Intake: 761.4 6 hour Output: 48 Daily Weight (today): 168 (prior day): 168
Having very low
urine output/hour

Pain/Pain Management:
Location:______ Duration: ________ Scale 1-10: _________ FLACC: 0
Intervention: _________ Evaluation (within 30 min): ________

ABG Analysis:
ABG’s pH PaCO2 PO2 HCO3 Interpretation
(time/date)
10-23-2019 7.21 58.3 455.2 23.0 (normal) Uncompensated
respiratory
acidosis
10-24-2019 7.35 (normal) 45.5 122.0 24.7 (normal) Compensated
respiratory
acidosis

Diagnostic Test: Results:

Chest X-ray (include 10-22-2019  atherosclerotic disease, possible pseudotumor at right lung base
date) 10-23-2019  severe emphysema with few opacities in right lower lung

Other Pertinent CT Head without contrast (10-22-2019)

diagnostic tests (include Communicating hydrocephalus
date)

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 Lab Test Normal Admission Day Prior Day of Care Reason for
Values Abnormal Value
Date 10-22-19 10-23-19 10-24-19
B
M

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 Na+ 132-146 151 150 147 Dehydration
K+ 3.5-5.0 4.2 3.9 4.2
Cl- 98-107 110 108 107 Dehydration
CO2 22-29 24 22 24
BUN 6-20 31 36 49 Dehydration + AKI
Creatinine 0.5-1.0 0.7 0.7 1.6 Dehydration + AKI
Glucose 74-99 134 150 189 Infection, stress
C Albumin 3.5-5.2 4.2 -------- --------
M Total Protein 6.4-8.3 7.5 -------- --------
P ALP (Alk Phos) 35-104 82 -------- --------
(+ ALT 0-32 8 -------- --------
B AST 0-31 11 -------- --------
M Total Bilirubin 0-1.2 < 0.2 -------- --------
El Calcium 8.6-10.2 9.4 9.3 8.2 Malnutrition
ec Magnesium 1.6-2.6 2.2 -------- 2.7 Poor kidney function
tr Phosphate 2.5-4.5 2.5 -------- 3.9
Lip Cholesterol -------- -------- -------- --------
id Triglycerides -------- -------- -------- --------
CB RBC 3.5-5.5 4.83 4.99 5.17
C Hgb 11.5-15.5 12.5 12.8 13.2
Hct 34-48 41.9 41.5 45.3
Platelets 130-450 312 368 408
WBC 4.5-11.5 8.3 12.4 22.0 Infection/pneumonia
Neutrophils 43-80 87.3
Lymphocytes 20-42 8.9 8.0 Rheumatoid arthritis
Monocytes 2.0-12.0 3.3 4.2
Eosinophils 0.0-6.0 0.0 0.0
Basophils 0.0-2.0 0.1 0.01
Co PT 9.3-12.4 43.2 62.1 105.9 Alpha-1 antitrypsin
ag INR 3.7 5.3 9.0 Alpha-1 antitrypsin
HPTT/PTT
Ca CK
rd CK MB
ia Troponin 0.0-0.03 < 0.01 < 0.01
c BNP
Ammonia 11.0-51.0 29.6
Lactic Acid 0.5-2.2 1.2

ECG Analysis: (based off of ECG strip)

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 1. Rate: 120 5. P Precedes each QRS: Yes/No
2. R-R Interval Regular: Yes/No 6. QRS Interval: 0.08 seconds
3. P wave present: Yes/No 7. QT Interval: 0.36 seconds
4. PR Interval: 0.12 sec Constant: Yes/No 8. ECG Interpretation: sinus tachycardia

Pathophysiology of primary diagnosis and/or surgery:

Hydrocephalus is an excessive accumulation of fluid in the brain. The excessive accumulation of CSF results in

an abnormal widening of spaces in the brain called ventricles. Communicating hydrocephalus occurs when the

flow of CSF is blocked after it exits the ventricles. It’s called communicating because the CSF can still flow

between the ventricles which remain open

Source Cited: ninds.nih.gov

Psychosocial Considerations:

Psychosocial considerations for a braindead patient are more about the family. Learning how to communicate

to the family in a sensitive manner during this stressful time

Priority Nursing Diagnoses:

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Priority # __2__

ND: Impaired cerebral tissue perfusion

General Goal: Have cerebral tissue perfusion

Outcome: patient will maintain stable temperature of 97-99 degrees on day of care

Interventions: Pt. Responses:

1. Monitor Temperature 1. Ranged 97.6-97.7 degrees

2. Monitor Blood Pressure 2. BP range 103/61-126/86

3. Monitor ventricle CSF Output 3. 5 every hour, clearish pink in color

4. Monitor reflexes 4. No gag, corneal reflex

5. Monitor level of consciousness 5. Patient unresponsive, no brain activity

Evaluation: Goal met, patient maintained temperature of 97-99 degrees on day of care

Priority # __1__

ND: impaired spontaneous ventilation

Outcome: Patient will initiate at least 1 breath over vent on day of care

Evaluation: Goal not met, vent respiratory rate set at 14. Pt’s respiratory rate was 14 on day of care

Priority # __3__

ND: Impaired family coping

Outcome: Family will verbalize understanding of patient’s situation on day of care

Evaluation: Goal met, spoke to patient’s family over the phone and they stated “mother’s brain dead and is

not going to wake up”

N4840 Daily Clinical Schedule: Interventions/Treatments

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 Time: 7 8 9 10 11 12
Complete Assessment q 2 hours

Vital Signs hourly

CVP
SpO2

Art Line Check (circ, line, bag)

IV Check q 4 hours

Meds as needed
Focused Assessment (specify):
Neuro

Hourly Urine Output

Mouth Care q 2 hours

Restraint Check
Check Lab Results

Turn q 2 hours

ECG Strip

Call Light/Rails

Medications

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Times Due Continuous PRN 8:00 9:00

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Brand Name 0.9 % NS Tylenol Ventolin HFA Alphagan

Generic Name Slo-salt Acetaminophen Albuterol Brimonidine

Dose 125 mL/hour 650mg 2.5mg 0.2% ophthalmic
solution
Route/How to Bolus @ 8:00 and Q 4hours PRN PO Q 4hour while 1 drop both eyes
Administer continuous awake every morning
Classification Mineral and Nonnarcotic Bronchodilator Alpha adrenergic
electrolyte analgesic agonist
replacement
Action Replacement in Unknown Decreased Selective alpha 2
deficiency states and mechanism, intracellular adrenergic
maintenance of perhaps by action calcium relaxes receptor agonist
homeostasis on PNS smooth muscle with a peak
airways ocular
hypotensive
effect
Reason Pt Receiving Treat low cardiac Fever or mild pain History of COPD Lowering
Medication output and low blood and asthma intraocular
pressure pressure
Contraindications Fluid retention, Cardiac disease, Neonates and
hypernatremia, NG hypertension, infants
suctioning, HF, hyperthyroidism,
severe renal or liver diabetes,
failure glaucoma
Major Adverse/Side HF, pulmonary Nervousness, Oral dryness,
Effects edema, restlessness, ocular
hypernatremia, tremor, chest hyperemia,
hypervolemia, pain, palpitations, burning and
hypokalemia, stinging,
irritation at IV site headache,
blurring, foreign
body sensation,
fatigue, ocular
pruritis
Nursing Assess fluid balance, Assess lung Correct
Implications/Teachin intake and output, sounds, pulse, and instillation of eye
g weight, edema, lung blood pressure drops
sounds before and after
administration,
observe for
wheezing
Times Due Q 8 hours 9:00 9:00 PRN

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Brand Name Ancef Lasix Neurontin Apresoline

Generic Name Cefazolin Furosemide Gabapentin Hydralazine

Dose 100 mL/hour 20 mg 400 mg 10 mg

Route/How to 1 g in dextrose 5% PO daily PO capsule 2x IV q 6 hour PRN

Administer 50 mL IVPB daily

Classification Anti-infective Diuretic Anticonvulsant Vasodilator

Action Binds to cell wall Inhibits the Mechanism of Direct acting

membranes reabsorption of action unknown, peripheral
causing cell death sodium and may affect arteriolar
chloride from the transport of amino vasodilator
loop of Henle and acids across and
distal renal tubule stabilize neuronal
membranes
Reason Pt Receiving Pneumonia Decrease ICP Prevent seizures High blood pressure
Medication SBP > 170
Contraindications Sensitive to Severe liver Renal
cephalosporin, disease, electrolyte insufficiency,
penicillin, renal depletion, hypersensitivity
impairment, GI diabetes, severe
disease, colitis renal impairment
Major Adverse/Side Diarrhea, nausea, Dehydration, Confusion,
Effects vomiting, rash, hypocalcemia, depression,
pain, seizures hypochloremia, dizziness,
hyponatremia, drowsiness, ataxia
hypomagnesemia,
hypokalemia,
hypovolemia,
metabolic alkalosis
Nursing Monitor bowel Assess fluid status, Monitor behavior
Implications/Teachin function, monitor daily weight, changes, seizure
g infection, monitor intake and output, activity, monitor
labs edema, lung labs
sounds, skin
turgor, and
mucous
membranes,
monitor labs

Times Due Nightly PRN PRN 8:00

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Brand Name Xalatan Milk of Magnesia Versed Spiriva

Generic Name Latanoprost Magnesium citrate Midazolam Tiotropium

Dose 0.005% 400mg/5mL 2mg 18mg

Route/How to Ophthalmic 1 drop 30mL PO daily IV q 1 hour Inhalation daily

Administer each eye

Classification Ophthalmic Laxative Benzodiazepines Anticholinergic

glaucoma agent
Action Lowers pressure Osmotically active Acts at many levels Acts as
inside the eye by in GI tract, of the CNS to anticholinergic by
increasing the drawing water produce selectively and
amount of fluid into lumen and generalized CNS reversibly
that drains from causing peristalsis depression inhibiting M3
the eye receptors in
smooth muscle of
airways
Reason Pt Receiving Increased Constipation Anxiety COPD and Asthma
Medication intraocular
pressure
Contraindications Swelling or Hypersensitivity to
infection in the tiotropium or
eye, herpes, ipratropium
retinal
detachment, eye
surgery
Major Adverse/Side Puffy eyelids, Dry mouth,
Effects stinging, burning, tachycardia,
redness of eyes, glaucoma, urinary
blurred vision, dry difficulty, urinary
or watery eyes, retention, rash
cold or flu
symptoms

Nursing Correct instillation Assess respiratory

Implications/Teachin of eye drops status, teach
g patient proper
administration

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Times Due 8:00 Nightly 8:00 Continuous
Brand Name Dulera Singulair Naprosyn Levophed

Generic Name Mometasone- Montelukast Naproxen Norepinephrine

formoterol
Dose 100-5mcg 10mg 500mg 2mcg/1min or
1.9mL/hour
Route/How to 2 puff 2 times daily PO tab PO capsule 2x 16mg in dextrose
Administer daily 5% 250mL IV

Classification Bronchodilator Leukotriene NSAID Vasopressor

antagonist
Action Decreased Antagonizes the Inhibits Stimulates alpha-
intracellular effects of prostaglandin adrenergic
calcium relaxes leukotrienes which synthesis receptors located
smooth airway mediate airway mainly in blood
muscles edema, smooth vessels, causing
muscle constriction of
constriction, vessels
altered cellular
activity
Reason Pt Receiving COPD and asthma COPD and asthma Moderate pain or Severe
Medication fever, arthritis hypotension and
shock
Contraindications Cardiac disease, Acute asthma Severe Vascular,
hypertension, attack, PKU, cardiovascular, mesenteric, or
hyperthyroidism, hepatic renal or hepatic peripheral
diabetes, glaucoma impairment, disease, history of thrombosis,
reduction of ulcer disease, hypertension,
corticosteroid history of GI bleed cardiovascular
therapy disease
Major Adverse/Side Nervousness, Agitation, anxiety, Dizziness, Anxiety, headache,
Effects restlessness, fatigue, cough, headache, tremor, dyspnea,
tremor, chest pain, abdominal pain, drowsiness, bradycardia,
palpitations, tremor, fever constipation, hypertension, low
dyspepsia, nausea urine output,
hyperglycemia

Nursing Assess lung Assess lung Assess pain, Assess BP, monitor
Implications/Teachin sounds, BP before sounds, allergy evaluate labs, ECG, monitor urine
g and after symptoms, assess bleeding time output, monitor
administration, rash for toxicity
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 observe wheezing

Times Due PRN 9:00 8:00 PRN

Brand Name Zofran Protonix Vitamin K Potassium
chloride
Generic Name Ondansetron Pantoprazole Phytoadione

Dose 4mg 40mg 100mL/hour 40mEq tab or

10mEq/100mL
Route/How to IV q 6 hours PO daily 10mg in dextrose 5% PO or IV
Administer 100mL IVPB

Classification Antiemetic Proton pump Fat-soluble vitamin Mineral and

inhibitor electrolyte
replacement
Action Blocks the effects Binds to an Required for hepatic Maintain acid-
of serotonin enzyme in the synthesis of blood base balance,
receptor sites, presence of coagulation factors II, isotonicity, and
located in vagal acidic gastric pH, VII, IX, and X electrophysiology
nerve terminals preventing the balance of the cell
and trigger zone final transport of
in the CNS hydrogen ions
Reason Pt Receiving Nausea Decrease risk of Prevention of Potassium
Medication GI ulcers, and hypoprothrombinemia replacement
VAP prophylaxis
Contraindications Severe hepatic Hypersensitivity,
insufficiency, impaired liver function
cirrhosis

Major Adverse/Side Diarrhea, Gastric upset, unusual

Effects flatulence, taste, flushing, rash,
abdominal pain, urticaria, anemia,
headache, rash allergic reactions

Nursing Monitor for Monitor for frank or

Implications/Teachin angioedema or occult bleeding,
g severe skin rash monitor pulse and BP,
monitor labs

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Times Due 9:00 9:00 9:00 8:00
Brand Name Carafate Forteo Zanaflex Effexor ER

Generic Name Sucralfate Teriparatide Tizanidine Venlafaxine

Dose 1g 20mcg 4mg 150mg

Route/How to PO tab 4x daily subQ daily PO 2x daily PO with breakfast

Administer

Classification Antiulcer agents Hormones Anti-spasticity Antidepressant

agent
Action Aluminum salt of Regulates calcium Acts as an agonist Inhibits serotonin
sucrose reacts with and phosphate at central alpha- and
gastric acid to form metabolism in adrenergic norepinephrine
a thick paste, bone and kidney receptor sites reuptake in the
which selectively by binding to CNS
adheres to ulcer specific cell
surface receptors
Reason Pt Receiving Peptic ulcer Treatment of Spasticity Anxiety/depression
Medication disease osteoporosis
Contraindications Renal failure, Paget’s disease, Renal impairment, Hypersensitivity,
diabetes, impaired unexplained concurrent concurrent use
swallowing increased alkaline antihypertensive with MAOi,
phosphate therapy cardiovascular
disease, impaired
renal function
Major Adverse/Side Dizziness, Orthostatic Anxiety, Abnormal dreams,
Effects drowsiness, hypotension, depression, anxiety, dizziness,
constipation, dry muscle spasms dizziness, headache,
mouth, nausea, sedation, insomnia,
pruritis, rash weakness, weakness, dry
hypotension, dry mouth, nausea,
mouth, diarrhea, vomiting,
sweating, rash constipation
Nursing Assess abdominal Assess bone Assess muscle Assess mental
Implications/Teaching pain and frank or mineral density, spasticity, monitor status and mood
occult blood in the monitor labs BP and pulse, changes, monitor
stool monitor labs BP and labs

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Times Due Nightly
Brand Name Verelan

Generic Name Verapamil

Dose 240mg

Route/How to PO nightly
Administer

Classification Calcium channel

blocker
Action Inhibits the
transport of
calcium into
myocardial and
vascular smooth
muscle cells,
resulting in
contraction
Reason Pt Receiving Management of
Medication hypertension and
angina
Contraindications 2nd or 3rd degree AV
block, systolic BP
<90, heart failure,
severe ventricular
dysfunction
Major Adverse/Side Arrhythmias,
Effects bradycardia, chest
pain, hypotension,
dysuria, epistaxis,
headache,
dizziness

Nursing Monitor BP and

Implications/Teachin pulse, monitor
g ECG, monitor
intake and output
daily, daily weight,
monitor for
constipation

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