NURS 2910

Plan of Care Evaluation

Student Name: Caitlin Martinez________________ Date: March 28th, 2013___________________
Week#:3-28-13_________________

Faculty: Cindy Ludwig_______________________

Instructions: Attach a copy of this form to each of you Clinical Plan of Care/Maps for grading purposes.
Sections:
1.

2.

3.

4.

5.
6.
7.

Patient Data includes:

20 points possible __20____
a. Physical data including Labs
b. Health history
c. All blanks and/or issues are addressed
Each medication includes:
20 points possible __20____
a. Name
b. Rationale
c. Side effects
d. Nursing implications-specific to this patient
Problem Identification includes
20 points possible __20____
a. Correctly lists individualized needs
b. Correctly identifies problems
c. Problems are prioritized and numbered each problem in priority of importance
d. Map includes at least three physiological problems, psychosocial/spiritual issues,
discharge planning and patient education(more towards end of semester)
e. Each problem includes:
i. Nursing diagnosis
ii. Data to support
iii. Medication
iv. Nursing treatment (interventions)
Planned interventions includes
10 points possible __10____
a. Interventions appropriate
b. Correctly prioritizes interventions
c. Assessments performed
d. Communication
e. Patient teaching-try and include pt teaching point for each nursing diagnosis
f. Discharge planning
Evaluation of Interventions includes
10 points possible _10_____
a. Evaluates physical interventions
b. Evaluates teaching
Critical Assessments are appropriate to Dx
10 points possible _10_____
Document focused assessment
Overall Care Map
a. Neatness/readable by faculty

10 points possible _10_____

b. Complete
Comments: Great job!

Total Points______100_________/100 = __100______%

CSU, STANISLAUS B.S.N.

CLINICAL PLAN OF CARE
Student Caitlin Martinez______________

Date of Care March 28th, 2013______ Room Number 389____

Patient Data
Admitting Diagnosis Intracerebral hemorrhage due to a stroke Age 45 Spiritual Focus Catholic Culture Hispanic
Patient Initials S.S.____ Gender Female________ Height 160 cm_______ Weight 89.7 kg
_______
Admitting Date 2/20/13____ Vital Signs: T 36.7 P 63 R 18 B/P 118/78 O2 Sat 96% on RA Pain Scale 9/10
Past Medical History Hypertension, anxiety, depression, migraines___________________
____________________________________________________________________________________________
Surgical History Breast augmentation, knee surgery
_____________________________________________
Diet Regular Activity Full assist/bedrest
Foley N/A_______ NG/Feeding Tube N/A________
Advance Directives:
Yes X (husband) No _______
Drains/ Tubes N/A __________________________
Code Status Full________ VS Freq q4h ________
Glucose Monitoring N/A TEDs/SCDs SCDs_____
Vascular Access:
PCA/Epidural N/A ____________ Telemetry N/A_______
IV Site: No IV; D/Cd on 3/17;she kept pulling them out IV Solution: N/A
Safety Considerations Fall risk_____
Dressing Changes PICC line dressing change
Labs to be drawn N/A____________
_ Scheduled Procedures Heat therapy, physical therapy
Notes on pathophysiology: Intracerebral hemmorhage
Intracerebral hemorrhage occurs when a diseased blood vessel within the brain bursts, allowing blood to leak inside the brain. (The name means within the cerebrum
or brain). The sudden increase in pressure within the brain can cause damage to the brain cells surrounding the blood. If the amount of blood increases rapidly, the
sudden buildup in pressure can lead to unconsciousness or death. Intracerebral hemorrhage usually occurs in selected parts of the brain, including the basal ganglia,
cerebellum, brain stem, or cortex. The most common cause of intracerebral hemorrhage is high blood pressure (hypertension). Since high blood pressure by itself
often causes no symptoms, many people with intracranial hemorrhage are not aware that they have high blood pressure, or that it needs to be treated.
Symptoms include
Sudden tingling, weakness, numbness, or paralysis of the face, arm or leg, particularly on one side of the body
Sudden, severe headache
Difficulty with swallowing or vision
Loss of balance or coordination
Difficulty understanding, speaking (slurring, confusion), reading, or writing
Change in level of consciousness or alertness, marked by stupor, apathy, lethargy, sleepiness, or coma
Treatments may include:
Anti-anxiety drugs and/or medication to control blood pressure
Anti-epileptic drugs for seizure control
Other medications necessary to control other symptoms, such as painkillers for severe headache and stool softeners to prevent constipation and straining
during bowel movements
Nutrients and fluids as necessary. These may be given through a vein (intravenously), or a feeding tube in the stomach (gastronomy tube), especially if the
patient has difficulty swallowing

Speech therapy, occupational therapy, physical therapy

Lab and Diagnostic Test Data

Test type(date)
Urinalysis
color

Normal
Range
Colorless-dark
yellow

Older Lab

Newes
t Lab

3/7
amber

3/25
yellow

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient

care & teaching

Check for pathologic

condition; this patient has an
intracranial hemorrhage, so
blood is showing up in her
urine

Abnormal color may indicate a pathologic disease

such as bleeding from an organ.
1. Monitor BP because this patient has an
intracranial hemorrhage and could become
extremely hypotensive (we want to keep BP low,
but not too low)
2. Obtain a blood draw to check hemoglobin,
hematocrit, PTT, INR, platelet count, and
fibrinogen
3. Monitor vitals and assess level of
consciousness (if LOC is decreases and ICP is
increased intubate patient and hyperventilate)
4. Initiate seizure therapy because patients who
have an ICH are at high risk for a seizure
5. Avoid hyperthermia with use of acetaminophen
Cloudy urine may be sign of WBCs, RBCs, or
bacteria in the urine
1. Monitor BP because this patient has an
intracranial hemorrhage and could become
extremely hypotensive
2. Obtain a blood draw to check hemoglobin,
hematocrit, PTT, INR, platelet count, and
fibrinogen
3. Monitor vitals and assess level of
consciousness (if LOC is decreases and ICP is
increased intubate patient and hyperventilate)
4. Initiate seizure therapy because patients who
have an ICH are at high risk for a seizure
5. Avoid hyperthermia with use of acetaminophen
Renal disease diminishes concentrating capability
(low sp. Gravity); dehydration seen with high
specific gravity
1. Check skin turgor of patient and I&O ratio to
check hydration
The kidneys assist in acid-base balance by
reabsorbing sodium and excreting hydrogen.
Acidic urine may indicate metabolic or respiratory
acidosis, starvation, dehydration, UTI. Alkaline

appearance

clear

hazy

clear

Check for bacteria/WBCs in

urine-signs of infection; the
haziness of this patients
urine is caused by blood in
the urine

sp. gravity

<1.030

1.020

1.015

Evaluate concentrating and

excretory power of the
kidneys; evaluates hydration

pH

5-8

5.0

5.0

Check kidney function

Test type(date)

Normal
Range

Older Lab

Newes
t Lab

Trend

Rationale
(specific to pt.)

glucose

negative

neg

neg

Could indicate diabetes or

renal glycosuria

bilirubin

negative

neg

Checks liver function; when

a patient has hemolysis, they
also will have bilirubin in the
urine

ketones

negative

neg

Checks control of diabetes;

this patient was vomiting a
lot after her stroke, so she
was probably malnourished
which is why ketones were in
her urine

blood

negative

250

neg

Checks for bladder , ureteral,

and urethral diseases; may
also indicate kidney disease;
this patient has an
intracranial hemorrhage, so
this is why blood is found in
the urine

Nursing Implications related to patient

care & teaching
urine indicates alkalemia
1. Check skin turgor and I&O ratios to check
hydration
2. If metabolic acidosis occurs patient may
experience nausea, vomiting, hypoxia, and
abdominal/chest pain
If present it reflects a degree of glucose elevation
in the blood (not controlling diabetes)
levels=Diabetes Mellitus, hyperglycemia, renal
glycosuria
When the level of glucose in the blood exceeds a
certain point, the kidneys will move excess
glucose into the urine. The exact number when
this occurs varies by person and depends on
kidney function, but is usually very high.
Can indicate liver injury due to gallstones or drug
toxicity

Poorly controlled diabetes and hyperglycemia

results in ketones in the urine; can also evaluate
for ketoacidosis. Ketones are found in the urine
after a person does not eat for 18 hours; it could
indicate that the person was really sick and could
not eat or was vomiting
1. Check for signs and symptoms of
hyperglycemia (polyuria, polydipsia, polyphagia,
weakness, malaise, weight loss)
2. Administer ondansetron to stop nausea and
vomiting
3. Assess nutritional status; provide nutrients
through an NG tube
4. Assess risk for aspiration
Hematuria suggests glomerulonephritis, renal
trauma, renal tumor, or UTI infection
1. Monitor BP because this patient has an
intracranial hemorrhage and could become
extremely hypotensive
2. Obtain a blood draw to check hemoglobin,
hematocrit, PTT, INR, platelet count, and
fibrinogen
3. Monitor vitals and assess level of

Test type(date)

Normal
Range

Older Lab

Newes
t Lab

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient

care & teaching
consciousness (if LOC is decreases and ICP is
increased intubate patient and hyperventilate)
4. Initiate seizure therapy because patients who
have an ICH are at high risk for a seizure;
administer Keppra
5. Avoid hyperthermia with use of acetaminophen
Sensitive indicator of kidney function; protein in
urine can indicate renal disease, infection, cancer,
heart failure
1. Monitor BP and HR
2. Monitor for signs of increased intracranial
pressure
3. Manage BP with antihypertensives (metoprolol,
lisinopril, enalapril, amlodipine)
3. Administer anti-anxiety medications (buspirone,
lorazepam)

protein

negative

75

neg

Check kidney function; the

reason this patient has
protein in her urine is
because she has high blood
pressure, an intracranial
hemorrhage, and is under
emotional stress

Urobilinogen

<1

normal

Determines cause of
elevated bilirubin levels; this
patient has lost some blood
due to her intracranial
hemorrhage (hematoma)
which may be why her
urobilinogen levels are high

Nitrate

negative

neg

neg

Checks for UTI

leukocytes

negative

neg

neg

Checks for UTI infection;

positive result may also
indicate kidney infection, or
sometimes inflammation or
infection of somewhere in
the body;

If bilirubin levels are because of overproduction,

so will urobilinogen levels. If bilirubin levels are
due to defects in metabolism or obstruction of
secretion, urobilinogen levels will not be elevated
level: hemolytic anemia, pernicious anemia,
hematoma, excessive ecchymosis
1. Evaluate the patient for hematoma; she has an
intraparenchymal hematoma
2. Obtain a blood draw to check hemoglobin,
hematocrit, platelet count, PTT, INR, etc.
3. Maintain BP and HR; monitor vitals, esp. RR
because if RR are increased, intracranial pressure
may be increased
Positive result indicates need for urine culture for
UTI
1. Monitor CBC especially WBCs for infection
2.Assess for signs and symptoms of infection
(fever, chills)
3. Assess for RBCs in the urinecould indicate a
UTI
5. Administer prescribed antibiotics

3/7

3/23

133

137

Checks kidney function; this

patient may have had low

Sodium is an electrolyte and a mineral; it help

keeps the water and electrolyte balance of the

Electrolyte
Profile
sodium

136-145

Test type(date)

Normal
Range

Older Lab

Newes
t Lab

Trend

Rationale
(specific to pt.)
levels due to loss of blood
and loss of fluids (since she
was vomiting on admission)

potassium

3.5-5.1

4.0

3.6

Kidney function

chloride

98-107

98

98

Kidney function

CO2

22-29

22

27

Regulated by kidneys; can

determine a breathing
disorder; this patient has

Nursing Implications related to patient

care & teaching
body.
Recent trauma, surgery, or shock may cause
levels; Decreased levels are caused by heart
failure, kidney disease, cirrhosis
1. Monitor signs of abnormal sodium values
(confusion, seizures, lethargy)
2. Check other electrolyte lab values and monitor
I&O
3. Assess for signs and symptoms of
hypernatremia (excessive thirst, tachycardia,
edema, weakness, lethargy) and hyponatremia
(nausea, vomiting, headache, confusion, fatigue)
4. Treat hypernatremia with increased intake of
fluids
5. Treat hyponatremia, the patient may be placed
on fluid restriction, given fluids containing sodium
content, or given Vasopressin if prescribed
levels: renal failure, infection, acidosis,
dehydration
levels: GI disorder, diuretics, insulin
administration, glucose administration
1. Watch for signs and symptoms of hypokalemia
(dysrhythmias, constipation, fatigue) and
hyperkalemia (nausea, weakness, bradycardia)
2. Monitor potassium values if patient is on
diuretics, digoxin, etc.
3. Monitor patients heart rate and BP
4. Administer potassium chloride if levels are less
than 3.8
levels: dehydration, metabolic acidosis, renal
tubular acidosis, kidney dysfunction
levels: overhydration, inappropriate secretion of
ADH, vomiting, HF, hypokalemia
1. Check skin turgor and I&O ratios to check for
hydration
2. Since this patients chloride levels are on the
edge of being low and her potassium has been
low too, potassium chloride can be administered if
potassium is less than 3.8 and this will also
increase her chloride levels
levels: severe vomiting, COPD, metabolic
acidosis
levels: chronic diarrhea, loop diuretics, renal

Test type(date)

Normal
Range

Older Lab

Newes
t Lab

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient

care & teaching

pneumonia of her L lung and

a completely collapsed L
lung which is impairing her
gas exchange and causing a
buildup of CO2 in the blood

failure, starvation, metabolic acidosis

1. Monitor respiratory patterns (depth, rate)
2. Monitor SpO2 levels
2. Provide oxygen therapy as ordered

Glucose random

70-110

192

115

Control of diabetes; may

increase due to stress and
infection also; this patient is
under high levels of stress
due to her intracranial
hemorrhage/stroke and
history of anxiety, so her
levels are increased due to
her SNS response

: diabetes mellitus, stress, chronic renal failure,

acute pancreatitis, diuretic therapy
: insulinoma, hypothyroidism, liver disease,
insulin overdose
1. Monitor blood glucose with FSBG; administer
insulin if prescribed
2. Assess for signs and symptoms of
hyperglycemia (polyuria, polydipsia, polyphagia,
weakness, malaise, weight loss) and
hypoglycemia (headache, dizziness, irritability,
fatigue, confusion, visual changes, hunger,
seizures, coma)

creatinine

0.5-1.0

0.6

0.4

Check renal function;

Healthy kidneys filter
creatinine and other waste
products from your blood.
The filtered waste products
leave your body in your
urine; low levels of creatinine
can be because of
decreased muscle mass
since this patient is on
bedrest

: glomerulonephritis, pyelonephritis, reduced

renal blood flow
: debilitation, decreased muscle mass
1. Monitor intake & output
2. Monitor for impaired tissue perfusion (edema)
3. Monitor nutrition status, especially albumin and
protein levels
4. Perform ROM exercises and muscle
strengthening exercises to maintain muscle mass
5. Need to monitor this value since the patient is
on lisinopril; excreted through kidneys

BUN

8-23

19

Checks renal function; this

patient is probably due to a
low-protein, high
carbohydrate diet; she
probably isnt getting enough
protein

Measures the amount of nitrogen in your blood

that comes from the waste product urea. Urea is
made when protein is broken down in your body.
Urea is made in the liver, filtered through the
kidneys and passed out of your body in the urine.
: hypovolemia, dehydration, starvation, sepsis
: liver failure, overhydration, malnutrition
1. Check for signs and symptoms of sepsis
2. Monitor WBCs
3. Obtain a blood differential, platelet test, and a
kidney function test
4. Assess nutrition status; provide meals higher in

Test type(date)

Normal
Range

Older Lab

Newes
t Lab

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient

care & teaching
protein if needed
5. 5. Need to monitor this value since the patient
is on lisinopril; excreted through kidneys

Total protein

6.4-8.3

7.6

6.8

Checks for renal function,

immune disorders, liver
dysfunction, impaired
nutrition, and chronic
edematous states; her levels
have gone down because
she is probably losing
muscle mass due to her
impaired mobility

: dehydration, inflammatory disease, nephritic

syndrome, hypercholesterolemia, acute/chronic
infection
:hemolysis, malnutrition, immune disorders
1. Assess nutritional status(albumin, protein, and
creatinine especially)
2. Provide high protein meals and encourage her
to eat most of her meal (she has been eating
anywhere from 25%-75% of her meals and she
refused breakfast the morning I took care of her)

albumin

3.5-5.2

4.3

4.3

Measures hepatic
function/nutritional status

calcium

8.8-10.2

9.3

9.5

Measure parathyroid
function, calcium metabolism

Monitor liver function tests

1. Assess patients nutritional status
2. Keep patient on a high protein diet since she is
on bed rest and has impaired
neurological/sensory perception
3. Encourage her to eat most of her meal
:hyperparathyroidism, hyperthyroidism
: renal failure, pancreatitis
A test for calcium in the blood checks the calcium
level in the body that is not stored in the bones.
Calcium is needed to build and fix bones and
teeth, help nerves work, make muscles squeeze
together, help blood clot, and help the heart to
work.
1. Assess patient for hypercalcemia (constipation,
increased thirst, muscle twitches, weakness) and
hypocalcemia (bradycardia, hypotension,
confusion)
2. If calcium levels drop it is not due to amlodipine
(a calcium channel blocker); it has no effect on
serum calcium levels

Test type(date)

Normal
Range

Older Lab

Newes
t Lab

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient

care & teaching

Bilirubin total

0.0-1.0

0.4

0.4

Evaluates liver function;

small amounts of older red
blood cells are replaced by
new blood cells every day.
And bilirubin is left after
these older blood cells are
removed; the liver helps
break down bilirubin so that it
can be removed by the body
in the stool risk for sepsis, so
an could be a sign

: hemolytic anemia, pernicious anemia, largevolume blood transfusion, cirrhosis, sepsis,

1. Need to monitor this value because patient is
taking acetaminophen and Norco; the max.
amount of acetaminophen per day is 3000mg; too
much acetaminophen can damage the liver

Alkaline
phosphatase
(ALP)

35-104

44

48

Measures the amount of the

enzyme ALP in the blood.
ALP is made mostly in the
liver and in bone with some
made in the intestines and
kidneys; detects liver and
bone disorders

: cirrhosis, metastatic tumor

: hypophosphatemia, malnutrition
1. Monitor liver function tests
2. Monitor skin color for jaundice
3. Monitor calcium levels because if it increases,
so will the patients ALP
4. Need to monitor this value because patient is
taking acetaminophen and Norco; the max.
amount of acetaminophen per day is 3000mg; too
much acetaminophen can damage the liver

SGOT/AST
(serum glutamic
oxaloacetic
transaminase/
aspartate
aminotransferase)

0-35

24

20

An enzyme found in high

amounts in heart muscle and
liver and muscle cells. It is
also found in lesser amounts
in other tissues; evaluates
liver function; directly related
to tissue damage

: liver damage, heart failure, necrosis

1. Assess for jaundice
2. Need to monitor this value because patient is
taking acetaminophen and Norco; the max.
amount of acetaminophen per day is 3000mg; too
much acetaminophen can damage the liver

SGPT/ALT
(serum glutamic
pyruvic
transaminase/
alanine
aminotransferase)

0-33

23

26

An enzyme found in the

highest amounts in the liver.
Injury to the liver results in
release of the substance into
the blood; checks liver
function; high levels
associated with tissue decay

: cirrhosis, necrosis, hepatitis, lack of blood flow

to the liver
1. Assess for jaundice
2. Assess tissue perfusion
3. Need to monitor this value because patient is
taking acetaminophen and Norco; the max.
amount of acetaminophen per day is 3000mg

globulin

2.1-3.5

3.3

2.5

Checks for infection or

certain diseases (chronic
inflammatory diseases)

: acute infection, hyperimmunization

1. Assess wounds
2. Monitor vital signs, WBCs
3. Monitor protein in blood

Test type(date)

Normal
Range

Older Lab

Newes
t Lab

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient

care & teaching
4. Monitor tissue perfusion and integrity

A/G ratio

0.9-2.0

1.7

eGFR Af-Am Fem

>60

>60

209

eGFR Other Fem

>60

>60

>60

Chemistry Profile
Magnesium

3/7
2.2

3/23

1.6-2.6

Checks for liver/kidney

function

:autoimmune disease, cirrhosis, kidney disease

A low A/G ratio may be caused by
underproduction of albumin. Normally, there is a
little more albumin than globulins.
1. Assess the patients nutritional status
2. Keep this patient on a high protein diet since
she is on bed rest and has impaired neurological
function and mobility

Estimates how much blood is

passing through the
glomeruli per minute; this
test is affected by race; when
a persons kidney function
declines due to disease, the
filtration rate decreases and
waste products accumulate
in the blood; is a calculation
based on serum creatinine
test

Estimates how much blood is

passing through the
glomeruli per minute; when a
persons kidney function
declines due to disease, the
filtration rate decreases and
waste products accumulate
in the blood; is a calculation
based on serum creatinine
test

Normal range: 90-120

Mild kidney damage: 60-89
Moderate kidney damage: 30-59
Severe Kidney damage: 15-29
Kidney failure: Less than 15
Decreased GFR: kidney damage
--Decrease in amount of urine, high blood
pressure (hypertension), urinating more or less,
feeling itchy, tiredness, N/V, loss of appetite,
swelling/numbness in hands/feet, muscle cramps
1. Monitor BG and BP to prevent further damage
2. Monitor creatinine
3. Monitor electrolyte balance and I&O
Normal range: 90-120
Mild kidney damage: 60-89
Moderate kidney damage: 30-59
Severe Kidney damage: 15-29
Kidney failure: Less than 15
Decreased GFR: kidney damage
--Decrease in amount of urine, high blood
pressure (hypertension), urinating more or less,
feeling itchy, tiredness, N/V, loss of appetite,
swelling/numbness in hands/feet, muscle cramps
1. Monitor BG and BP to prevent further damage
2. Monitor creatinine
3. Monitor electrolyte balance and I&O

A magnesium test can find

the cause related to difficulty
breathing;

10

Magnesium is an important electrolyte needed for

proper muscle, nerve, and enzyme function. It
also helps the body make and use energy and is
needed to move other electrolytes (potassium and
sodium) into and out of cells.

Test type(date)

Normal
Range

Older Lab

Newes
t Lab

Trend

Rationale
(specific to pt.)

Hemograms
WBC x 10^3

4.8-10.8

3/7
15.0

3/23
6.2

Check for infection; patient

had MRSA and it was treated
with vancomycin

RBC x 10^6

3.80-5.20

4.48

4.34

Number of RBCs in system

Hemoglobin
(HGB)

11.5-15.5

13.2

13.2

The protein in your red blood

cells that carries oxygen; low
because she is anemic, has
been experiencing shortness
of breath due to collapsed
lung and pneumonia

Hematocrit

35-47

39.5

38.5

MCV (mean
corpuscular
hemoglobin)

80-94

88.1

88.8

MCHC (mean
corpuscular
hemoglobin
concentration)

32-36

33.4

34.3

Measurement of RBC
number and volume; this
patient has a hemorrhoid
and a stage 2 pressure ulcer
that bleeds a lot, so her
hematocrit may be low due
to loss of blood
Measures avg. volume, or
size, of a single RBC; used
to classify anemias;
extremely high WBC counts
may increase the MCV
Measure of the avg.
concentration or percentage
of hemoglobin within a single
RBC; levels of hemoglobin
are low, so this value is low
as a result

11

Nursing Implications related to patient

care & teaching
:infectious diseases, inflammatory disease,
severe stress, tissue damage
: autoimmune disease, bone marrow failure,
disease of liver or spleen
1. Administer antibiotics as ordered,
2. Monitor temp, HR
3. Monitor ulcer sites for redness, drainage,
increased pain
4. Patient was previously on vancomycin for
MRSA
: dehydration, kidney disease, low O2 levels,
smoking
: blood loss, chronic kidney disease, hemolysis,
long term infections
: anemia, blood loss
Symptoms of low hemoglobin/anemia: pale skin,
weakness, shortness of breath, fainting,
palpitations, chest pain, restless legs syndrome
1. Check iron levels
2.Monitor CBC
3. Administer vitamins to treat deficiency of
vitamins
: Erythrocytosis, COPD, severe dehydration
: anemia, hemorrhage, renal disease
1. Assess pressure ulcer and hemorrhoid
2. Monitor CBC
3. Monitor iron levels and treat with vitamin
supplements if ordered
: megaloblstic anemias (vit. B12 deficiency
: iron-deficiency anemia
1. Monitor WBC
2. Monitor for signs and symptoms of infection
(fever, chills, BP, temp, etc)
: iron-deficient anemia, thalassemia
: spherocytosis

Test type(date)

Normal
Range

Older Lab

Newes
t Lab

Trend

Rationale
(specific to pt.)

RDW (red cell

distribution width)

11.5-14.5

12.8

13.5

Indicates variation in RBC

size; helps classify certain
types of anemia; classifies
different types of anemia

PLT x10^3

130-400

393

301

Amount of platelets in your

blood which are responsible
for blood clotting;

Nursing Implications related to patient

care & teaching
This patient has anemia, which is why her levels
are high
: iron-deficiency anemia, B12 or folate-deficiency
anemia
1. Administer vitamins as ordered
: malignant disorders, polycythemia vera, irondeficiency anemia
: hemorrhage, immune thrombocytopenia,
hemolytic anemia
1. Monitor PT, INR
2. Monitor patient for unusual bleeding (bleeding
gums, abnormal bruising, bloody stools)
3. Monitor for signs of DVT (pain in legs, edema,
redness or warmth in the area affected)
4. Prevent blood clots by putting the patient on an
anticoagulant, using SCDs
Signs and symptoms of
thrombocytopenia: easy or excessive bruising,
superficial bleeding into the skin that appears as a
rash of pinpoint-sized reddish-purple spots
(petechiae), usually on the lower legs, prolonged
bleeding from cuts, spontaneous bleeding from
gums or nose, blood in urine or stools
Signs and symptoms of thrombocythemia
(blood clotting): headache, dizziness or
lightheadedness, chest pain, weakness, fainting,
temporary vision changes, numbness or tingling
of the hands and feet, redness, throbbing and
burning pain in the hands and feet
(erythromelalgia), mildly enlarged spleen

MPV (mean
platelet volume)

7.4-10.4

9.2

7.8

Measure of the volume of a

large number of platelets

: valvular heart disease, massive hemorrhage

: aplastic anemia

Blood culture (3/8): s. aureus organisms present (was put on vancomycin); vanco trough draw (3/10) value
was 7.4); CT scan of head/brain (3/8) showed increased intracranial pressure, slight hydrocephalus,
intraparenchymal hematoma; CXR (3/7) showed PICC line overlaying SVC; urine culture (3/17) no growth
12

Medication Allergies: cephalexin

Medications
Generic & Trade Name
Drug classification
(Therapeutic &
Pharmacologic)
amlodipine (Norvasc)
antihypertensive; calcium
channel blocker
New med

dose/Route
Frequency

Action of drug and

Rationale
(specific to Pt)

Significant Side
Effects

Nursing Implications

Patient Teaching

1 tab (5mg) PO
daily

Action: Inhibits the

transport of calcium into
myocardial and vascular
smooth muscle cells,
resulting in inhibition of
excitation-contraction
coupling and subsequent
contraction; systemic
vasodilation resulting in
decreased blood pressure

headache, peripheral
edema

-Monitor BP and pulse before

therapy, during dose titration,
and periodically during therapy
-Monitor I&O ratios and daily
weight
-Assess for signs of CHF
(peripheral edema,
rales/crackles, dyspnea, weight
gain, JVD)
-Total serum calcium
concentrations are not affected
by this med
-May be administered without
regard to meals

-Take as directed, even if

feeling well; take missed
doses as soon as possible
unless almost time for next
dose; dont double doses
-Avoid large amounts of
grapefruit juice
-Change positions slowly
because this med may
cause orthostatic
hypotension
-May cause drowsiness or
dizziness; avoid driving and
other activities requiring
alertness
-Avoid concurrent use of
alcohol or OTC
medications, esp. cold
preparations
-Notify provider if irregular
heartbeats, dyspnea,
swelling of hands or feet,
pronounced dizziness,
nausea, constipation, or
hypotension occurs
-wear protective
clothing/sunscreen to
prevent photosensitivity
reactions

Rationale: This patient has

a history of hypertension

13

buspirone (Buspar)
antianxiety agent

0.5 tab(2.5mg)
PO bid

New med

Action: Binds to serotonin

and dopamine receptors in
the brain; increases
norepinephrine
metabolism in the brain

dizziness, drowsiness,
headache, insomnia,
palpitations, nausea,
rashes, numbness

-Assess degree and

manifestations of anxiety before
and periodically during therapy
-Does not appear to cause
physical or psychological
dependence or tolerance
-May be administered with food
to minimize gastric irritation;
food slows but does not alter
extent of absorption

dizziness, drowsiness,
headache, insomnia,
palpitations, nausea,
rashes, numbness

-Assess degree and

manifestations of anxiety before
and periodically during therapy
-Does not appear to cause
physical or psychological
dependence or tolerance
-May be administered with food
to minimize gastric irritation;
food slows but does not alter
extent of absorption

Rationale: Patient has a

medical history of having
anxiety, so this med will
manage that for her

buspirone (Buspar)
antianxiety agent
New med

1 tab (5 mg) PO
bid

Action: Binds to serotonin

and dopamine receptors in
the brain; increases
norepinephrine
metabolism in the brain
Rationale: Patient has a
medical history of having
anxiety, so this med will
manage that for her

14

-Take as directed; take

missed doses as soon as
possible if not just before
next dose; do not doube
doses
-May cause dizziness or
drowsiness; avoid driving
and other activities
requiring alertness
- Avoid concurrent use of
alcohol or other CNS
depressants
-Consult provider before
taking OTC medications or
herbal products
-Notify provider if any
chronic abnormal
movements occur
(dystonia, motor
restlessness, involuntary
facial movements)
-Take as directed; take
missed doses as soon as
possible if not just before
next dose; do not doube
doses
-May cause dizziness or
drowsiness; avoid driving
and other activities
requiring alertness
- Avoid concurrent use of
alcohol or other CNS
depressants
-Consult provider before
taking OTC medications or
herbal products
-Notify provider if any
chronic abnormal
movements occur
(dystonia, motor
restlessness, involuntary
facial movements)

docusate (Colace)
laxative, stool softener

1 cap (100 mg)

PO bid

New med

Action: Promotes
incorporation of water into
stool, resulting in softer
fecal mass; may also
promote electrolyte and
water secretion into the
colon; prevention of
constipation

mild cramps

-Asses for abdominal distention,

presence of bowel sounds, and
pattern of bowel function
-Asses color, consistency, and
amount of stool produced
-Administer with full glass of
water or juice
-May administer on empty
stomach for more rapid results
-Do not administer within 2
hours of other laxatives

-Advise patients that

laxatives are for short-term
therapy
-Advise patient not to use if
they have abdominal pain,
nausea, vomiting, or fever
-Soft, formed bowel
movement, usually within
24-48 hrs; therapy may take
3-5 days for results

dizziness, weakness

-Assess patient for CNS

adverse effects throughout
therapy, characterized as:
somnolence and fatigue
(asthenia), coordination
difficulties (ataxia, abnormal
gait, or incoordination), and
behavioral abnormalities
(agitation, hostility, anxiety,
apathy, emotional lability,
depersonalization, depression)
and usually occur during the first
4 weeks of therapy.
-May cause in RBC and WBC
and abnormal liver function tests
-may be administered without
regards to meals
Administer tablets whole; do not
crush, chew, or break XR tablets
-Discontinue gradually to
minimize the risk of increase in
seizure frequency

-Take as directed; take

missed doses as soon as
possible, but do not double
doses
-May cause dizziness and
somnolence; avoid driving
or other activities requiring
alertness
-Notify provider if
pregnancy is planned or
suspected

Rationale: Patient is on
bedrest

levetiracetam (Keppra)
anticonvulsant;
pyrrolidine
New med

1 tab (500 mg)

PO bid

Action: Appears to inhibit

burst firing without
affecting normal neuronal
excitability and may
selectively prevent
hypersynchronization of
epileptiform burst firing
and propagation of seizure
activity; decreased
incidence and severity of
seizures
Rationale: Since this
patient had and
intracranial hemorrhage
she is at high risk for
seizures/stroke, so this
med will prevent seizures
and also decrease the
severity of a seizure if she
has one

15

lisinopril (Prinivil)
antihypertensive; ACE
inhibitor
New med

1 tab (500 mg)

PO bid

Action: ACE inhibitors

block the conversion of
angiotensin I to the
vasoconstrictor
angiotensin II; prevent the
degradation of bradykinin
and other vasodilatory
prostaglandins; plasma
rennin levels and
aldosterone levels;
systemic vasodilation

hypotension, cough,
taste disturbances,
angioedema

Rationale: This patient has

a history of hypertension,
so this med will manage
that

16

-Monitor BP and pulse

frequently during initial dose
adjustment and periodically
during therapy
-Assess for signs of
angioedema (dyspnea, facial
swelling)
-Monitor BUN, creatinine, and
electrolyte levels periodically
-Monitor CBC periodically
-May cause in AST, ALT,
alkaline phosphatase, serum
bilirubin, uric acid, and glucose

-Take at same time each

day, even if feeling well;
take missed doses as son
as possible, but do not
double doses
-Avoid salt substitutes or
foods containing high levels
of potassium or sodium
-Change positions slowly to
minimize effects of
orthostatic hypotension
-Consult provider before
taking any OTC meds or
herbal supplements
-May cause dizziness;
avoid driving and activities
requiring alertness
-Medication may impair
taste; but resolves in 8-12
weeks
-Notify provider if
experiencing rash, mouth
sores, sore throat, fever,
swelling of extremities,
irregular heartbeat, dry
cough, etc
-Encourage patients to
comply with additional
interventions for
hypertension (weight
reduction, low sodium diet,
discontinue smoking,
regular exercise, etc.)

metoprolol tartrate
(Lopressor)
antianginals,
antihypertensive; betablocker

1 tab (100 mg)

PO BID

New med

Action: Blocks stimulation

of beta1 (myocardial)adrenergic receptors;
decreases BP and HR;
decreases rate of
cardiovascular mortality in
patients with HF

bradycardia, CHF,
pulmonary edema,
fatigue, weakness, ED

Rationale: This patient has

hypertension and heart
failure, so this med will
decrease his BP and will
slow the rate of
cardiovascular mortality

paroxetine (Paxil)
antianxiety agent;
antidepressant; selective
serotonin reuptake
inhibitor
New med

1 tab (20mg) PO
daily

Action: Inhibits neuronal

reuptake of serotonin in
the CNS, thus potentiating
the activity of serotonin;
has little effect on
norepinephrine or
dopamine; antidepressant
action; decreased
frequency of panic attacks,
OCD, or anxiety

neuroleptic malignant
syndrome, suicidal
thoughts, dizziness,
weakness,
constipation, dry
mouth

Rationale: The patient is

taking another antianxiety
agent (buspirone) for her
anxiety, but this one
focuses more on blocking
serotonin reuptake
whereas the other one
increases norepinephrine

17

-Monitor BP, ECG, and pulse

frequently
-Monitor intake & output ratios
and daily weight
-Assess routinely for dyspnea,
rales/crackles, weight gain,
peripheral edema, JVD
-May cause BUN, serum
lipoprotein, potassium,
triglycerides, and uric acid levels
-May cause ANA titers, blood
glucose, serum alkaline
phosphatase, LDH, AST, and
ALT levels
-Take apical pulse before
administering. If <50 bpm or if
arrhythmia occurs, WITHHOLD
-HOLD if SBP<100
-Administer with meals
-Monitor appetite and nutritional
intake; weigh weekly
-Monitor mental status
(orientation, mood, behavior);
notify provider if there is an
increase in anxiety,
nervousness, or insomnia
-Assess for suicidal tendencies
-Assess for serotonin syndrome
(mental changes, autonomic
instability, neuromuscular
aberrations, GI symptoms)
-Administer as a single dose in
the morning; may administer
with food to avoid GI irritation
-Tablets should be swallowed
whole; DO NOT crush, break,
chew
-Taper to avoid potential
withdrawal reations

-May cause drowsiness;

avoid driving or other
activities requiring alertness
-Change positions slowly to
minimize orthostatic
hypotension
-This medication may
increase sensitivity to cold
-Avoid caffeine in excessive
amounts
-Notify provider if slow
pulse, difficulty breathing,
wheezing, cold hands,
dizziness, or confusion
occur

-Take as directed; take

missed dose as soon as
possible, but do not double
dose
-Daily doses should be
decreased slowly; abrupt
withdrawal may cause
dizziness, agitation, anxiety,
nausea
-May cause drowsiness or
dizziness; avoid driving or
activities requiring alertness
-Avoid alcohol or other CNS
depressants
-Frequent mouth rinses,
good oral hygiene, and
sugarless gum or candy
can prevent dry mouth
-Inform provider if you
become pregnant, have
headache, weakness,
nausea, anorexia, anxiety,
or insomnia

triamcinolone topical
(Kenalog 0.1% topical
cream)
corticosteroid; antiinflammatory

1 application
topical cream tid
for 7 days (end
date=4/2/13) to
the antecubital
fossa

Action: Suppresses normal

immune response and
inflammation

100 mL
(1000mg) IVPB
q6h PRN fever;
infuse over 15
min

Action: Inhibits the

synthesis of
prostaglandins that may
serve as mediators of pain
and fever, primarily in the
CNS; analgesia;
antipyresis

New med

acetaminophen (Ofirmev)
antipyretic, Nonopioid
analgesic
New med

allergic contact
dermatitis

Rationale: This patient is

having some itching on her
antecubital fossa, so this
cream will reduce the
itching by reducing
inflammation and the
immune response to the
reaction

hepatic failure,
hepatotoxicity

Rationale: This patient has

had an occasional fever,
so this medication is
prescribed in case she has
a fever again

18

-Assess affected skin prior to

and daily during therapy. Note
degree of inflammation and
pruritus. Notify physician or
other health care professional if
symptoms of infection
(increased pain, erythema,
purulent exudate) develop.
-Apply ointment or
cream sparingly as a thin film to
clean, slightly moist skin. Wash
hands immediately after
application. Apply occlusive
dressing only if specified by
physician or other health care
professional.
-Assess overall health status
and alcohol usage before
administering
-Patients who are malnourished
or chronically abuse alcohol are
at higher risk of developing
hepatotoxicity with chronic use
of usual doses of this drug
-Assess amount, frequency, and
type of drugs taken in patients
self-medicating, esp. with OTC
drugs
-Asses fever; note presence of
associated signs (diaphoresis,
tachycardia, and malaise)
-Administer with full glass of
water

-Instruct patient on correct

technique of medication
administration. Emphasize
importance of avoiding the
eyes. If a dose is missed, it
should be applied as soon
as remembered unless
almost time for the next
dose.
-Caution patient to use only
as directed. Avoid using
cosmetics, bandages,
dressings, or other skin
products over the treated
area unless directed by
health care professional.
-Take exactly as directed
and do not take more than
recommended; chronic
excessive use of >4g/day
may lead to hepatotoxicity
-Avoid alcohol
-Check labels on OTC
medications; avoid taking
more than one drug with
acetaminophen
-Notify provider if discomfort
or fever is not relieved by
routine doses or if fever is
greater than 39.5 or lasts
longer than 3 days

acetaminophen (Tylenol)
antipyretic, Nonopioid
analgesic

2 tab (650mg)
PO q4h PRN
headache

New med

Action: Inhibits the

synthesis of
prostaglandins that may
serve as mediators of pain
and fever, primarily in the
CNS; analgesia;
antipyresis

hepatic failure,
hepatotoxicity

Rationale: This patient has

history of headaches and
also has headaches that
are probably due to the
increase in intracranial
pressure

acetaminophen (Tylenol)
antipyretic, Nonopioid
analgesic
New med

20.3 mL
(650mg) liquid
NG q4h PRN
headache if
unable to take
orally

Action: Inhibits the

synthesis of
prostaglandins that may
serve as mediators of pain
and fever, primarily in the
CNS; analgesia;
antipyresis

hepatic failure,
hepatotoxicity

Rationale: This patient has

history of headaches and
also has headaches that
are probably due to the
increase in intracranial
pressure

19

-Assess overall health status

and alcohol usage before
administering
-Patients who are malnourished
or chronically abuse alcohol are
at higher risk of developing
hepatotoxicity with chronic use
of usual doses of this drug
-Assess amount, frequency, and
type of drugs taken in patients
self-medicating, esp. with OTC
drugs
-Asses fever; note presence of
associated signs (diaphoresis,
tachycardia, and malaise)
-Administer with full glass of
water
-Assess overall health status
and alcohol usage before
administering
-Patients who are malnourished
or chronically abuse alcohol are
at higher risk of developing
hepatotoxicity with chronic use
of usual doses of this drug
-Assess amount, frequency, and
type of drugs taken in patients
self-medicating, esp. with OTC
drugs
-Asses fever; note presence of
associated signs (diaphoresis,
tachycardia, and malaise)
-Administer with full glass of
water

-Take exactly as directed

and do not take more than
recommended; chronic
excessive use of >4g/day
may lead to hepatotoxicity
-Avoid alcohol
-Check labels on OTC
medications; avoid taking
more than one drug with
acetaminophen
-Notify provider if discomfort
or fever is not relieved by
routine doses or if fever is
greater than 39.5 or lasts
longer than 3 days
-Take exactly as directed
and do not take more than
recommended; chronic
excessive use of >4g/day
may lead to hepatotoxicity
-Avoid alcohol
-Check labels on OTC
medications; avoid taking
more than one drug with
acetaminophen
-Notify provider if discomfort
or fever is not relieved by
routine doses or if fever is
greater than 39.5 or lasts
longer than 3 days

acetaminophenhydrocodone (Norco 32510mg)

opioid analgesic
New med

2 tab PO q4h
PRN severe
pain; max
dose=3000mg
acetaminophen
in 24 hrs.

Action: Binds to opiate

receptors in the CNS;
alters the perception of
and response to painful
stimuli while producing
generalized CNS
depression

Confusion, dizziness,
sedation,
hypotension,
constipation, nausea

-Assess BP, pulse, respirations

before and during therapy. If
RR< or equal to 10, assess
sedation level
-Asses bowel function routinely
-Asses pain type, location, and
intensity prior to and one hour
after therapy (peak)
-May be administered with food
or milk to avoid GI irritation

abdominal cramps,
nausea

-Assess patient for abdominal

distention, presence of bowel
sounds, and usual pattern of
bowel function
-Assess color, consistency, and
amount of stool produced
-Suppository or enema can be
given at the time a bowel
movement is desired
-Lubricate suppositories with
water or water-soluble lubricant
before insertion
-Encourage patient to retain the
suppository or enema 15-30 min
before expelling

Rationale: This patient has

been having some pain
9/10

bisacodyl (Dulcolax
Laxative)
laxative, stimulant
laxative
New med

1 suppository
(10mg) rectal
daily PRN
constipation

Action: stimulates
peristalsis; alters fluid and
electrolyte transport,
producing fluid
accumulation in the colon;
evacuation of the colon
Rationale: This patient is
on bed rest and is taking
some medications that can
cause constipation.

20

-Prolonged use may lead to

physical dependence
-Teach patient how and
when to ask for and take
medication
-May cause drowsiness or
dizziness
-Change positions slowly to
avoid orthostatic
hypotension
-Avoid alcohol and other
CNS depressants
-Turn, cough, and deep
breathe every 2 hours
-Advise patients that
laxative use should be used
only for short-term therapy;
prolonged therapy may
cause electrolyte imbalance
and dependence
-Advise patient to increase
fluid intake to at least 15002000 mL/day during therapy
to prevent dehydration
-Encourage patients to use
other forms of bowel
regulation (increasing bulk
in the diet, increasing fluid
intake, or increasing
mobility)
-Instruct patients with
cardiac disease to avoid
straining during bowel
movements
-Do not use if you have
abdominal pain, fever,
nausea, or vomiting

diphenhydramine
(Benadryl)
allergy, cold, and cough
remedies;
antihistamines;
antitussives

1 cap (25 mg)

PO q4h PRN for
itching

Action: Antagonizes the

effects of histamine at H1receptor sites; does not
bind to or inactivate
histamine; significant CNS
depressant and
anticholinergic properties

drowsiness, anorexia,
dry mouth

-Assess nausea, vomiting,

bowel sounds, and abdominal
pain
-Assess itching before
administration
-May cause sedation and
confusion
-Administer with meals or milk to
minimize GI irritation; capsule
can be opened and empties into
water or food

hypotension, cough,
taste disturbances,
angioedema

-Monitor BP and pulse

frequently during initial dose
adjustment and periodically
during therapy
-Assess for signs of
angioedema (dyspnea, facial
swelling)
-Monitor BUN, creatinine, and
electrolyte levels periodically
-Monitor CBC periodically
-May cause in AST, ALT,
alkaline phosphatase, serum
bilirubin, uric acid, and glucose

New med
Rationale: This patienthas
been having some itching
sue to a rash that she has.

enalapril (Vasotec)
antihypertensive, ACE
inhibitor
New med

0.5 mL (0.625
mg) IV q6h PRN
SBP
above/equal to
140

Action: ACE inhibitors

block the conversion of
angiotensin I to the
vasoconstrictor
angiotensin II; prevent the
degradation of bradykinin
and other vasodilatory
prostaglandins; plasma
rennin levels and
aldosterone levels;
systemic vasodilation
Rationale: This patient has
a history of hypertension,
so this med will manage
that

21

-Take as directed; do not

exceed prescribed does
-May cause drowsiness or
dizziness
-May cause dry mouth
instruct patient in good oral
hygiene
-Teach sleep hygiene
techniques (dark room,
quiet, bedtime ritual, etc)
-Use sunscreen/protective
clothing to prevent
photosensitivity reactions
-Take at same time each
day, even if feeling well;
take missed doses as son
as possible, but do not
double doses
-Avoid salt substitutes or
foods containing high levels
of potassium or sodium
-Change positions slowly to
minimize effects of
orthostatic hypotension
-Consult provider before
taking any OTC meds or
herbal supplements
-May cause dizziness;
avoid driving and activities
requiring alertness
-Medication may impair
taste; but resolves in 8-12
weeks
-Notify provider if
experiencing rash, mouth
sores, sore throat, fever,
swelling of extremities,
irregular heartbeat, dry
cough, etc
-Encourage pts. to comply
with other interventions for
hypertension (weight
reduction, low sodium diet,
quit smoking, regular
exercise, etc.)

ibuprofen (Motrin)
antipyretics,
antirheumatics, nonopiod
analgesics, nonsteriodal
anti-inflammatory

1 tab (400mg)
PO tid with meal
PRN moderate
pain

Action: Inhibits
prostaglandin synthesis;
decreases pain and
inflammation; reduces
fever

headache,
constipation, GI
bleeding, hepatitis,
nausea, vomiting

1 cap (2 mg) PO
PRN diarrhea

Action: Inhibits peristalsis

and prolongs transit time
by a direct effect on nerves
in the intestinal muscle
wall; reduces fecal volume,
increases fecal viscosity
and bulk while diminishing
loss of fluid and
electrolytes

drowsiness,
constipation

Home med

loperamide (Imodium AD)

antidiarrheals
New med

lorazepam (Ativan)
anesthetic adjunct,
antianxiety agent,
sedatie/hypnotic,
benzodiazepine

1 tab (1 mg) PO
q4h PRN
agitation

Rationale: This patient

previously had some
problems with diarrhea, so
this med was prescribed
for that and its still
prescribed in case she has
diarrhea again
Action: Depresses the
CNS, probably by
potentiating GABA, an
inhibitory neurotransmitter

dissiness, drowsiness,
lethargy

22

-Assess for signs and symptoms

of GI bleeding (tarry stools,
lightheadedness, hypotension),
renal dysfunction (elevated BUN
and creatinine levels, decreased
urine output), and hepatic
impairment (elevated liver
enzyme, jaundice)
-Assess pain (type, location, and
intensity) prior to and 1-2 hours
following administration
-Patients should be well
hydrated before administration
to prevent renal adverse
reaction
-For rapid initial effect,
administer 30 min before or 2 hr
after meals
-May be administered with
meals, milk, or antacids to
decrease GI irritation
-Tablets may be crushed and
mixed with fluid or food
-Assess frequency and
consistency of stools and bowel
sounds prior to and during
therapy
-Assess fluid and electrolyte
balance and skin turgor for
dehydration
-Administer with clear fluids to
prevent dehydration, which may
accompany diarrhea

-Take with a full glass of

water and remain in an
upright position for 15-30
min after administration
-Take missed doses as
soon as possible; do not
double doses
-Avoid alcohol, aspirin,
acetaminophen, and other
OTC drugs and herbal
supplements
-Do not take for more than
10 days for pain or more
than 3 days for fever
-Consult provider if rash,
itching, visual disturbances,
tinnitus, weight gain,
edema, epigastric pain,
dyspepsia, black stools, etc.

-Conduct regular assessment of

continued need for treatment
-Assess degree and
manifestations of anxiety and
mental status (orientation,

-Take as directed
-Should be used for short
term use only
-Taper lorazepam by 0.05
mg q 3 days to decrease

-Take as directed; do not

take missed doses and do
not double doses
-May cause drowsiness;
avoid driving and activities
requiring alertness
-Frequent mouth rinses,
good oral hygiene, and
sugarless gum or hard
candy can minimize dry
mouth
-Avoid alcohol and other
CNS depressants
-Notify provider if diarrhea
persists or if fevr, abdominal
pain, or distention occurs

Rationale: Patient has

history of anxiety and has
been agitated due to
overestimation of her
abilities

New Med

lorazepam (Ativan)
anesthetic adjunct,
antianxiety agent,
sedatie/hypnotic,
benzodiazepine

1 tab (1 mg) PO
q6h PRN
breakthrough
anxiety

New med

dissiness, drowsiness,
lethargy

Rationale: Patient has

history of anxiety and has
been agitated due to
overestimation of her
abilities

New Med

ondansetron (Zofran)
antiemetics, 5-HT3
antagonists

Action: Depresses the

CNS, probably by
potentiating GABA, an
inhibitory neurotransmitter

2 mL (4 mg) IV
push q6h PRN
N/V

Action: Blocks the effects

of serotonin at 5-HT3receptor sites located in
vagal nerve terminals and
the chemoreceptor trigger
zone in the CNS.

Headache,
constipation, diarrhea

Decreases incidence and

23

mood, behavior) prior to and

throughout therapy
-Following parenteral
administration, keep patient
supine for at least 8 hours and
observe closely
-Dilute immediately before use
with an equal amount of sterile
water for injection, D5W, or
0.9% NaCl for injection
-Administer at a rate not to
exceed 2 mg/min or 0.05 mg/kg
over 2-5 mins
-Rapid administration could
result in apnea, hypotension,
bradycardia, or cardiac arrest
-Conduct regular assessment of
continued need for treatment
-Assess degree and
manifestations of anxiety and
mental status (orientation,
mood, behavior) prior to and
throughout therapy
-Following parenteral
administration, keep patient
supine for at least 8 hours and
observe closely
-Dilute immediately before use
with an equal amount of sterile
water for injection, D5W, or
0.9% NaCl for injection
-Administer at a rate not to
exceed 2 mg/min or 0.05 mg/kg
over 2-5 mins
-Rapid administration could
result in apnea, hypotension,
bradycardia, or cardiac arrest
-Assess for nausea, vomiting,
abdominal distention, bowel
sounds prior to and following
admin.
-Asses pt. for extrapyramidal
effects (involuntary movements,
facial grimacing, rigidity,
shuffling walk, trembling of

withdrawal symptoms

-Take as directed
-Should be used for short
term use only
-Taper lorazepam by 0.05
mg q 3 days to decrease
withdrawal symptoms

- Advise pt. to notify health

care provider immediately if
involuntary movements of
eyes, face, or limbs occur.

severity of nausea and

vomiting following
chemotherapy or surgery

hands) during therapy

-IV: administer undiluted
(2mg/mL) immediately before
induction of anesthesia or
postoperatively if nausea and
vomiting occur shortly after
surgery. Administer over 2-5
mins.

Rationale: Patient was

vomiting upon admission,
so this medication was for
that and its still prescribed
in case she gets nauseous
again and vomits
potassium chloride (KDur 20)
mineral and electrolyte
replacement/supplement

1 tab (20 mEq),

tab ER, PO PRN
potassium
replacement

Action: Maintain acid-base

balance, isotonicity, and
electrophysiologic balance
of the cell. Activator in
many enzymatic reactions;
essential to transmission
of nerve impulses;
contraction of cardiac,
skeletal, and smooth
muscle; gastric secretion;
renal function; tissue
synthesis; and
carbohydrate metabolism.

arrhythmias,
abdominal pain,
diarrhea, flatulence,
N/V

Rationale: This patient had

low levels of potassium
(hypokalemia), so this med
was used to treat this

24

-Assess for signs and symptoms

of hypokalemia (weakness,
fatigue, U wave on ECG,
arrhythmias, polyuria,
polydipsia) and hyperkalemia
-Monitor serum potassium
before and periodically during
therapy. Monitor renal function,
serum bicarbonate, and pH.
Determine serum magnesium
level if patient has refractory
hypokalemia; hypomagnesemia
should be corrected to facilitate
effectiveness of potassium
replacement. Monitor serum
chloride because hypochloremia
may occur if replacing
potassium without concurrent
chloride
-ymptoms of toxicity are those of
hyperkalemia (slow, irregular
heartbeat; fatigue; muscle
weakness; paresthesia;
confusion; dyspnea; peaked T
waves; depressed ST
segments; prolonged QT
segments; widened QRS
complexes; loss of P waves;
and cardiac arrhythmias).
-Administer with or after meals
to decrease GI irritation; Tablets
and capsules should be taken
with a meal and full glass of
water.

--Explain to patient purpose

of the medication and the
need to take as directed,
especially when concurrent
digoxin or diuretics are
taken. A missed dose
should be taken as soon as
remembered within 2 hr; if
not, return to regular dose
schedule. Do not double
dose.
-Instruct patient to avoid
salt substitutes or low-salt
milk or food unless
approved by health care
professional. Patient should
be advised to read all labels
to prevent excess
potassium intake.
-Instruct patient to report
dark, tarry, or bloody stools;
weakness; unusual fatigue;
or tingling of extremities.
Notify health care
professional if nausea,
vomiting, diarrhea, or
stomach discomfort
persists.

potassium chloride (KDur 20)

mineral and electrolyte
replacement/supplement

2 tab (40 mEq),

tab ER, PO PRN
potassium
replacement

Action: Maintain acid-base

balance, isotonicity, and
electrophysiologic balance
of the cell. Activator in
many enzymatic reactions;
essential to transmission
of nerve impulses;
contraction of cardiac,
skeletal, and smooth
muscle; gastric secretion;
renal function; tissue
synthesis; and
carbohydrate metabolism.

arrhythmias,
abdominal pain,
diarrhea, flatulence,
N/V

Rationale: This patient had

low levels of potassium
(hypokalemia), so this med
was used to treat this

25

-K+ levels 3.8-3.9: give 20 mEq

x1
3.5-3.7: give 40 mEq x1
3-3.4 mEq: give 40 mEq x1 plus
20 mEq x1
2.9 or less: notify physician
-Assess for signs and symptoms
of hypokalemia (weakness,
fatigue, U wave on ECG,
arrhythmias, polyuria,
polydipsia) and hyperkalemia
-Monitor serum potassium
before and periodically during
therapy. Monitor renal function,
serum bicarbonate, and pH.
Determine serum magnesium
level if patient has refractory
hypokalemia; hypomagnesemia
should be corrected to facilitate
effectiveness of potassium
replacement. Monitor serum
chloride because hypochloremia
may occur if replacing
potassium without concurrent
chloride
-ymptoms of toxicity are those of
hyperkalemia (slow, irregular
heartbeat; fatigue; muscle
weakness; paresthesia;
confusion; dyspnea; peaked T
waves; depressed ST
segments; prolonged QT
segments; widened QRS
complexes; loss of P waves;
and cardiac arrhythmias).
-Administer with or after meals
to decrease GI irritation; Tablets
and capsules should be taken
with a meal and full glass of
water.
-K+ levels 3.8-3.9: give 20 mEq
x1
3.5-3.7: give 40 mEq x1
3-3.4 mEq: give 40 mEq x1 plus
20 mEq x1

--Explain to patient purpose

of the medication and the
need to take as directed,
especially when concurrent
digoxin or diuretics are
taken. A missed dose
should be taken as soon as
remembered within 2 hr; if
not, return to regular dose
schedule. Do not double
dose.
-Instruct patient to avoid
salt substitutes or low-salt
milk or food unless
approved by health care
professional. Patient should
be advised to read all labels
to prevent excess
potassium intake.
-Instruct patient to report
dark, tarry, or bloody stools;
weakness; unusual fatigue;
or tingling of extremities.
Notify health care
professional if nausea,
vomiting, diarrhea, or
stomach discomfort
persists.

potassium chloride (KCl)

potassium chloride (KCl)
pregabalin (Lyrica)
anticonvulsant; nonopioid
analgesic
New med
New order 3/27

20 mEq=15 mL
liquid PO
40 mEq=30 mL
liquid PO

Same as above, but liquid

form
Same as above, but liquid
form and different dose

1 cap (50mg)
PO tid

Action: Binds to calcium

channels in CNS tissues
which regulate
neurotransmitter release.
Does not bind to opioid
receptors; Decreased
neuropathic or postherpetic pain. Decreased
partial-onset seizures.

Same as above, but

liquid form
Same as above, but
liquid form and
different dose
suicidal thoughts,
dizziness, drowsiness,
dry mouth

Rationale: This patient had

been having some nerve
pain in her left arm; she
also is at risk for seizures
because of her ICH

26

2.9 or less: notify physician

Same as above, but liquid form
Same as above, but liquid form
and different dose
- Monitor closely for notable
changes in behavior that could
indicate the emergence or
worsening of suicidal thoughts
or behavior or depression.
- Pregabalin should be
discontinued gradually over at
least 1 wk. Abrupt
discontinuation may cause
insomnia, nausea, headache,
and diarrhea when used for pain
and may cause increase in
seizure frequency when treating
seizures.
-May be administered without
regards to meals

Same as above, but liquid

form
Same as above, but liquid
form and different dose
-Take medication as
directed. Do not discontinue
abruptly; may cause
insomnia, nausea,
headache, or diarrhea or
increase in frequency of
seizures.
- May cause dizziness,
drowsiness, and blurred
vision; avoid driving or
activities requiring alertness
- Report unexplained
muscle pain, tenderness, or
weakness, especially if
accompanied by malaise or
fever. Discontinue therapy if
myopathy is diagnosed or
suspected or if markedly
elevated creatine kinase
levels occur.
-Notify provider if thoughts
about suicide or dying,
attempts to commit suicide;
new or worse depression;
new or worse anxiety;
feeling very agitated or
restless; panic attacks;
trouble sleeping; new or
worse irritability; acting
aggressive; being angry or
violent
- Avoid alcohol or other
CNS depressants

Concept Mapping
Step 2. List clinical manifestations under each nursing diagnosis and other relevant data to support each diagnosis, including lab
data, medications, interventions, and assessment findings. All medical & nursing interventions should be found in one or more of the
boxes.

ND #5 Risk for impaired tissue integrity

Data to support: bedrest, impaired neurological
function, impaired sensory function, LUE
paralysis, LLE severely weak, incontinent, rash
on antecubital fossa, impaired mobility, stroke,
rash on R antecubital fossa, Kenalog
Expected outcome/Goal: Patient will regain integrity of
skin surface; report any altered sensation or pain at site
of skin impairment; demonstrate understanding of plan
to heal skin and prevent reinjury

LA8/2011

27

ND # 4 Decreased cardiac output

Data to support: Hypertension, anxiety,
decreased cerebral tissue perfusion r/t stroke
and intracranial hemorrhage, lisinopril,
amlodipine, buspirone, metoprolol,
paroxetine, enalapril, lorazepam
Expected outcome/Goal: Expected outcome/Goal:
Patient will demonstrate adequate cardiac output
as evidenced by BP, HRR within normal
parameters, strong peripheral pulses

Concept Mapping
Evaluate Effects of Nursing Actions- Patient Outcomes, Documentation (Done During Clinical)
ND #1 Risk for impaired cerebral perfusion
Patient Response
r/t stroke and intracranial hemorrhage
1. ND/Nursing
Care:
Risk for impaired cerebral
Data
to support: Stroke,
intracranial
Nursinghypertension,
Actions(NIC)
hemorrhage,
increased
intracranial
pressure,
slight
hydrocephaly,status q4h
Assess neurological
altered sensation and mobility, lisinopril,
amolodipine, enalapril

On this floor neuro checks must be done q4h. At 0715 when

we went in to see our patient for the first time she was
7. Discharge
completely asleep. We tried
waking her up and she would open
This patient will probably be discharged to a
Chief Medical Diagnosis: Intracranial
her eyes for a min and then
fall
back
sleep.
said she
long term
care to
facility;
theyShe
are planning
on
hemorrhage due to stroke
was cold and we covered moving
her up,herbut
she wouldnt
up for
to Mercy
acute rehabwake
in
Priority Assessments: ABCs, monitor
Sacramento.
need to be
WNL,
us. vital
We let her sleep and came
back Labs
in around
0945
tovitals
wake
need
to
be
stable,
pain
needs
to
be
signs especially BP, HR, RR, and temp.
(fever
is
her up to give her her meds. She was confused about where
manageable, no signs and symptoms of
common after an ICH and needs toshe
be treated
was, but knew who she
was and the date. As she
infection, no signs and symptoms of increased
aggressively with acetaminophen and
cooling to wake up and be stimulated she was more alert
continued
intracranial pressure, neurological status needs
devices), neurological assessmentsand
q4h,oriented
pain
and was having
conversations with us.
to befull
stable

Expected outcome/Goal: Patient will maintain a

stable level of consciousness, neurological status,
cognition, and motor/sensory function. Patient will
demonstrate stable vital signs and absence of signs of
increased ICP.

Assess motor response to simple

assessments, reinforcement of limitations, bed

rails x4, bed alarm on at all times, She
bed locked
commands
was able
and in low position, frequent checks on her in

8. Pt Education
The importance of controlling her hypertension,
eating meals that are nutritional, exercising daily
(however, she probably will not be fully functional).
So, I should teach her about her current state and go
over her limitations, so that she is aware of what she
can and probably cant do. Teach her family (she
Monitor
BPdaughters)
(watchabout
for hypotension;
has a husband
and two
taking care
of her and about her condition, so that they
understand whats going on. Explain the importance
of physical therapy in her recovery.

LA8/2011

perfusion r/t stroke and intracranial hemorrhage

to follow all commands when I told her to wiggle

her fingers and toes and
move each limb; however, the left arm
ND #3 Risk for injury r/t risk for seizure and
and left leg barely moved
when Iand
asked
her to. She
is able to
neurological
musculoskeletal
impairment
scootr/therself up in bedData
by tobending
her right
leg and pushing
support: cognitive
impairment,
ND #2 Sensory/neurological impairment
neurological
impairment,
musculoskeletal
herself up. Physical therapy
worked
with her
today and got her
intracranial hemorrhage
paralysis,
increased
intracranial
Data to support: impaired urination, LUE
paralysis,
to stand
up and sit on impairment,
the commode
and
also move
herself
pressure, LLE extremely weak, LUE paralysis,
LLE severely weak, stroke, intracranial
hemorrhage,
down the halls with her
wheelchair.
restraints (x4 bed rails), tries to get out of bed
cerebral edema

without assisstance, forgets limitations,

may
indicate
bleed)
At 0715
and at
1200
it was 118/78.
This
overestimates,
Lyrica,
amlodipine
(orthostatic
Expected
outcome/Goal:
Patient will maintain
stable her BP was 130/96
hypotension),
busprirone,
Keppra,
lisinopril
sensory and motor function. Patient will demonstrate
stable
patient has hypertension, so she is on antihypertensive
vital signs and level of consciousness.
hypotension),
paroxetine,
medications. The night(orthostatic
shift nurse
let us know
that Norco
her BP ran
around 114/62 last night.
Expected outcome/Goal: Patient will

Monitor HR and rhythm

At 0715 her HR was 62 and at 1200 it was 63. The night shift
nurse let us know that her HR the night before was running
between 63-87. When doing her physical assessment I listened
to her heart sounds and she has a normal rate and rhythm.

Monitor RR (irregularities may indicate increased ICP)

At 0715 her RR was 20 and at 1200 it was 18. She wasnt in

any distress besides the fact that she was in a lot of pain after
physical therapy, so we gave her medication. Her breathing
was easy and unlabored.

28

2. ND/Nursing Care: Neurological impairment r/t intracranial hemorrhage

Nursing Actions (NIC)
Assess ROM
When doing my physical assessment I had the patient do some
ROM exercises. She can move her right arm and leg with no
complications. However, she can barely move her left arm and
can move her left leg if she really focuses hard. I can passively
move her leg around, but when I went to move her left arm
around she had a shooting nerve pain run through her arm all
the way to her back.

LA8/2011

Assess sensation

I assessed sensation in her extremities when doing her

physical assessment. She can feel light touch, pressure, and
pain in her right arm and leg. But, she can barely feel any
sensation in her left arm and leg. She said she could feel it, but
it was very light.

Assess eye movements

Her pupils PERRLA (equal, round, reactive to light, and

accommodate). She was able to follow my finger movements
with just her eyes as well.

Assess muscle strength

When doing her physical assessment I assessed her muscle

strength. She can squeeze my fingers in her right hand, but not
in my left. She can push her arm against my hand on her right
side. She cannot squeeze my fingers with her left hand and
cannot push her arm against my hand. She can push her right
foot against my hand and push her toes to the ceiling. She can
also lift her right leg against my hand. She cannot lift her left
leg against resistance and cannot push her feet against
resistance or raise her toes to the ceiling.

Reinforce her limitations

The patient tried getting out of bed because she wanted to use
the commode instead of the bed pan, and I had to remind her
that she cant get up by herself because shes really weak and
could get seriously hurt. She voiced understanding and
stopped trying to get out of bed and waited for me to get the
bed pan for her.
29

3. ND/Nursing Care: Risk for injury r/t risk for seizure and neurological
And musculoskeletal impairment
Nursing Actions(NIC)
Make sure to put up bed rails x4
This patient forgets her limitations and overestimated what she
can do, so she tries to get out of bed on her own a lot. We had
to make sure that all of her side rails were up at all times. We
would double check them before we left the room and I would
go in and check whenever someone else left her room
(physical therapy, etc). She had a fall on 3/20 in the hospital.

LA8/2011

Make sure bed alarm is on after leaving room

Same with the side rails; we would check her bed alarm every
time we left her room to make sure that it was on.

Administer anticonvulsants

At 0945 we administered her amlodipine and lisinopril. At 0715

her BP was 130/96, and at 1200 her BP was 118/78, so the
medications were working

Stand in front of her while she uses commode

When PT got her to stand up and move to the commode I had

to stand in front of her and wait until she was done going to the
bathroom (which she never did because she couldnt go) to
make sure that she didnt fall forward out of the commode due
o her instability. She didnt seem to mind me standing there
and was explaining to me how she was grateful that PT got her
up to go on the commode because she hated using the bed
pans because they were so uncomfortable and made it hard for
her to go to the bathroom.

Reinforce limitations

At one point during the day she was very emotional and
agitated. She told me that she was just gonna go home and
sleep in her own bed and that shed be fine at home and didnt
need to stay in the hospital. I had to tell her that she needed to
stay in the hospital to build her strength up because she
wouldnt be able to get around her house if she went home now
and could get hurt and would end up back in the hospital. She
voiced her understanding and ended up telling me about how
she knows she needs to be here, but she just wishes her family
could be there all the time because she needs them right now

30

4. ND/Nursing Care: Decreased cardiac output

Nursing Actions(NIC)
Monitor BP

Monitor HR

At 0715 her HR was 62 and at 1200 it was 63. The night shift
nurse let us know that her HR the night before was running
between 63-87. When doing her physical assessment I listened
to her heart sounds and she has a normal rate and rhythm.

Assess for edema

During her physical assessment I assessed her for any edema

and she didnt have any.

Monitor pulse oximetry

At 0715 her SpO2 was 98% and at 1200 her SpO2 was 96%. It
may have been a little lower at 1200 because she had fallen
asleep in a position where her neck was bent and she was
sliding down in her bed. We repositioned her and raised the
head of her bed a little bit after that.

Administer antihypertensives

At 0945 we administered the patients amlodipine and lisinopril.

Before we gave it her BP was 130/96 and at 1200 it was
118/78.

Teach her normal BP range

When I went to take her vitals at 1200, she asked me what her
BP was and I told her it was 118/78. She asked if that was
good and so I explained to her that it was and that she wants to
see her BP around 120/80 or less. She voiced her
understanding.

5. ND/Nursing Care: Risk for impaired tissue integrity

Nursing Actions(NIC)
Turn patient q2h

LA8/2011

At 0715 her BP was 130/96 and at 1200 it was 118/78. This

patient has hypertension, so she is on antihypertensive
medications. The night shift nurse let us know that her BP ran
around 114/62 last night.

31

I didnt have to turn this patient every 2 hours because she

moved around in her bed a lot on her own and would change
positions from laying on her back to laying on her left side. But I
would go in and make sure that she had changed positions and
that she was comfortable. I repositioned pillows under her arms
and helped her reposition herself sometimes.

LA8/2011

Assess skin

This patients skin integrity looked really good. It was dry, warm
to touch, and intact with not edema or wounds. She did have a
very small rash on her right antecubital fossa that was a little
itchy.

Provide bed bath

I helped give this patient a bed bath to maintain her skin

integrity and keep her clean. At first she didnt want to have one
because she was really agitated in the morning and she said
she was cold, but we told her it would probably make her feel a
lot better, so she said she wanted one.

ROM exercises

I peformed some range of motion exercises with her to assess

her mobility, but also to get her arms and legs moving to keep
her skin integrity maintained. She tolerated the exercises well,
except for when I went to pick up her left arm she had a
shooting nerve pain run through her arm all the way to her back
that was really painful.

Ask her if she needs to use bed pan every

few hours to prevent incontinence

This patient was having a really hard time voiding. She

feel the sensation that she had to go to the bathroom, but when
she would try to go, she wasnt able to. After she told me she
had to go the first time and wasnt able to, I would come into
her room every once in a while to check on her and see if she
wanted to try again. She tried about 5 times that day using the
commode/bed pan and finally voided about 450 mL around
1300.

32

SOAP Note
S- A 45-year-old woman admitted to the hospital on February 20th, 2012 for an intracranial
hemorrhage secondary to hypertension. She states that she was taking her daughter to the
radiologist for an x-ray when she had sudden numbness in her left arm. She had a
ventriculostomy on 3/20. Her past medical history includes hypertension, anxiety, depression,
and migraines. Her past surgical history includes a breast augmentation and a knee surgery, both
of unknown dates. Patient is alert and oriented x3 to person, place, and time; she forgets that she
is in Modesto and thinks she is in San Jose. Patient uses the pain scale (0-10) to rate her pain.
Her home medications include
O- Patient is extremely drowsy and sleeping. 0715 VS: T:36.8 BP:130/96 P:62 RR: 20
SpO2:98% RA 1200 VS T:36.7 BP:118/78 P:63 RR: 18 SpO2:96% RA
Neuro-Alert and oriented x3; patient thinks that she is in San Jose; forgets that she is at DMC in
Modesto; overestimates abilities, forgets limitations, is very impulsive; on restraints (bed alarm
on and side rails up x4); pupils PERRLA; can show two fingers on each hand; can wiggle toes;
cannot lift/move L arm; very weak movements in L leg; some sensation to touch and pain on L
side
Cardiovascular: Normal rate and rhythm; apical pulse corresponds to radial pulse; S1 and S2
sounds present; no S3 or S4; no murmurs; good capillary refill in nail beds; no edema in
peripheral limbs; peripheral pulses (radial and pedal) +2 bilaterally symmetric; no IV access
Respiratory: easy, unlabored breathing, lung sounds are clear
GI: active bowel sounds x4 quadrants; no distention or tenderness; LBM 3/28
GU: having trouble voiding; feels the sensation of having to void, but then cant; straight cath
yesterday (3/27) 400 mL; voided in bed pan today 450 mL
Skin-Skin is dry, warm to touch, with no signs of breakdown; patient complains of itching on R
antecubital fossa where there was a rash; however, it is almost completely gone now; no edema
A- Risk for impaired cerebral perfusion r/t stroke and intracranial hemorrhage,
Sensory/neurological impairment r/t intracranial hemorrhage, Risk for injury r/t risk for seizure
and neurological and musculoskeletal impairment; Intracranial hemorrhage secondary to
hypertension
P- The plan for this patient is to eventually move her to a long term care facility (Mercy acute
rehab in Sacramento). Physical therapy is going to continue working with her as well as the
occupational therapist. We are trying to work with her to get her to be able to transfer herself
from her wheelchair to the commode. In order to move to a long care facility her vitals need to
remain stable too, as well as her neurological status. She needs to have labs WNL and her pain
needs to be manageable.

LA8/2011

33

Student Clinical Self-Appraisal

Weekly (turn in with Care Plan/Map)
Student Caitlin Martinez______ Course ___________ Instructor Cindy Ludwig_____
Instructions: Please evaluate your performance during clinical today using the following
concepts:
Patient Advocate
Professional Demeanor
Flexible
Critical Thinking
Communication/rapport
Peer Support
Self-Initiated
Team Player
Skill Acquisition
Safety
Organized
Educator
Leadership
Well-prepared
Dependable
Nursing Process
Knowledgeable
Areas of Strength Today (Date)3/28/13___
Areas Needing Growth-Include plan of
This week my area of strength was
improvement
communication. I didnt get to do a ton of skills
this week, but I did get to talk to my patient
I want to continue working on my
more this week. Although she was confused
communication and I also want to choose a
and agitated in the morning and hard to
more challenging patient where I can gain
communicate with I was able to comfort her
new skills and experience new things. I
when she was crying and in pain and missing think that by choosing a more challenging
her family. I was also able to explain a lot of
patient next time I will continue to learn new
things to her and reinforce that she couldnt
things and grow. I want to work a little more
just do things on her own right now because
on my leadership too by taking the initiative
shes so weak that she could get seriously
to do things with my patient and letting my
hurt. I feel a little more comfortable with the
nurse know that I can do pretty much
charting/computer system. I also really feel
everything with her. Im really looking
comfortable taking the initiative to do
forward to the next two weeks in GI and PO.
everything for my patient, even the charting. I
Im going to try to use my leadership skills
explained to my nurse how I could chart and
and really let them know that I want to do as
showed her how she could review it and she
much as I can!
was really nice and seemed excited to learn
how to do it. We had a few little difficulties with
the med administration because we couldnt
figure out why it still said pending even
though she put her name as a witness for
each med, but we figured it out together.
Instructor Comments: Im glad that you are starting to be more independent from the nurse
and really taking that initiative to care for your patient. At this point I want you to do your
assessment, vitals, accuchecks, repositioning, ADLs, etc without having the RN tell you. I
know you will do great in PO/GI and great idea to practice being assertive!

LA8/2011

34

LA8/2011

35