CSU, STANISLAUS B.S.N.

CLINICAL PLAN OF CARE

Patient Data
Student: JoAnne Saba

Date of Care: 4/10/2014

Code Status: Full

Gender: F
Age: 72
Height:
Weight:
Spirituality: Christian Church
Ethnicity: Hispanic
Admitting Diagnosis: Aspiration Pneumonia, Respiratory Failure
Vital Signs: T: 36.5oC
P: 83
R: 24
B/P: 152/98
O2 Sat: 97% via mechanical ventilator Pain Scale & Scale Type: Denies Pain
History related to this admission: CVA (bedbound/nonverbal), Insulin-Dependent Diabetes Mellitus, Pneumonia, Seizure, TIA, Thyroid Dysfunction,
Anemia (transfusions q3mo), Shortness of Breath,
Past Medical History: CAP, Hyperlipidemia, Convulsions, Hypertension, Failure to Thrive
Admitting Date: 03/31/2014 POD: N/A
Surgical History & Date: PEG, endoscopic placement of gastrostomy tube
*No Surgery Dates Available
Diet: Tube Feeding
(Osmolite 1.2 Rate: 55mL/hr)
Advance Directives: No
Isolation: Standard Precaution VS Freq: q4h
Vascular Access:
IV : Central IV DG (Left Basilic PICC, 3 lumen)
IV Solution & Rate: NS 0.9%, 10 mL/h
Oxygen: Ventilator 30% FiO2
Respiratory Treatments: Trach Suctioning
Labs to be drawn day of care: N/A
Scheduled Procedures day of care: N/A
Procedures done this admission: CXR

Activity: Bed bound, reposition q2h

Foley: Removed 4/6
NG/Feeding Tube: Gastric Tube
Drains/ Tubes: N/A
Glucose Monitoring: q6h
DVT Prophylaxis: DVT stockings
PCA/Epidural: N/A
Telemetry: N/A
Safety Considerations: Fall Risk
Restraints: N/A
Dressing Changes & Frequency: PICC dressing q7days
Wound: Pressure Ulcer (right buttock, left groin, left knee, right knee, coccyx)Open to air, barrier applied.; Skin Tear, right arm- closed, open to air, barrier
applied

Notes on pathophysiology: Aspiration pneumonia is an inflammation in the lungs caused by the inhalation of vomit, food, or liquid. Respiratory
failure is when the respiratory system fails and does not proper exchange gases so that you have an imbalance of oxygen and carbon dioxide.

LA8/2011

Lab and Diagnostic Test Data

LABS

WBC

RBC

Normal Range

4-11

3.8-5.2

RESULT 1

RESULT 2

RESULT 3

6.7

4.9

4.8

4/3; 0340

4/9; 0635

4/10; 0630

2.65 (L)

2.79 (L)

2.8 (L)

4/3; 0340

4/9; 0635

4/10; 0630

Purpose

Aids in evaluation of infection,

neoplasm, allergy, or
immunosuppression. increased
WBC indicate these. Elevated or
levels indicate infection or sepsis
in the body.

Helps to determine the amount of

ongoing bleeding and evaluation of
anemia

Reason for abnormal lab values

r/t diagnosis & nursing
implications
Increased levels: infection,
leukemic neoplasia, malignancy,
trauma, tissue necrosis,
inflammation, dehydration, thyroid
storm, steroid use
Decreased levels: drug toxicity,
bone marrow failure, overwhelming
infections, dietary deficiency (i.e.
B12, iron), bone marrow filtration,
autoimmune disease, hyperspelnism
Assess for hypotension and trends
of temperature change, Monitor for
infection and hydration status,
assess for malnutrition.
Variations can indicate anemia,
cancer, or hemorrhage
Increased levels: Anxiety and
stress, dehydration with
hemoconcentration ( decreased
blood volume unchanged RBC
count)
Decreased levels: Hemorrhage,
nutritional deficit, overhydration,
renal disease (decreased
erythropoietin production)
Monitor hydration status, monitor
for signs of bleeding, assess diet,
assess for signs of kidney disease
Test done to assess for bleeding
Pt taking Heparin and is on tube
feedings which could cause a
decrease in nutritional status. Pt is
also anemic and requires blood
transfusions q3 months. G-tube
leaking as well causing area around
it to bleed due to burning from

LA8/2011

Hgb

11-15.5

8.4 (L)

8.7 (L)

8.8 (L)

4/3; 0340

4/9; 0635

4/10; 0630

Hemoglobin aids in the transport

of oxygen from the lungs to
peripheral tissues. increased
amount of Hgb expresses lower
perfusion levels from oxygen

stomach acid.
Increased levels: Congestive HF.
COPD, dehydration,
hemoconcentration erythrocytosis
(total blood volume is decreased,
RBC remains the same)
Decreased levels: Anemias, blood
loss, bone marrow hyperplasia,
cirrhosis, chronic disease, liver
retention, hemorrhage, IV overload,
renal disease, nutritional deficit
(especially in iron, vitamins, and
folic acid)
Monitor SpO2, Assess for signs of
anemia, assess for malnutrition

Hct

35-47

26.1 (L)

27 (L)

27 (L)

4/3; 0340

4/9; 0635

4/10; 0630

the indirect measure of RBC

number and volume

Pt taking Heparin and is on tube

feedings which could cause a
decrease in nutritional status. Pt is
also anemic and requires blood
transfusions q3 months. G-tube
leaking as well causing area around
it to bleed due to burning from
stomach acid.
Increased levels: erythrocytosis,
congenital heart disease,
polycythemia vera, severe
dehydration, severe COPD
Decreased levels: anemia,
hemoglobinopathy, cirrhosis,
hemolytic anemia, hemorrhage,
dietary deficiency, bone marrow
failure, prosthetic valves, renal
disease, pregnancy, leukemia
Monitor hydration status, assess for
signs of heart and renal disease,
assess for bleeding, assess for
malnutrtion
Pt taking Heparin and is on tube
feedings which could cause a
decrease in nutritional status. Pt is
also anemic and requires blood

LA8/2011

MCV

80-98

98.5 (H)

96.8

96.3

4/3; 0340

4/9; 0635

4/10; 0630

average volume of a single RBC.

used to classify anemias

transfusions q3 months. G-tube

leaking as well causing area around
it to bleed due to burning from
stomach acid.
Increased levels: pernicious
anemia (B12 deficiency), Folic
Acid Deficiency, antimetabolite
therapy, alcoholism, chronic liver
disease,
Decreased levels: iron-deficiency
anemia, thalassemia, anemia of
chronic illness
Assess for liver disease, assess for
nutrient deficiency, assess for
anemia

MCH

MCHC

RDW

27-32

32-36

11.5-14.5

31.6

31.4

31.5

4/3; 0340

4/9; 0635

4/10; 0630

32.1

32.4

32.7

4/3; 0340

4/9; 0635

4/10; 0630

20.6 (H)

20.6 (H)

20.4 (H)

4/3; 0340

4/9; 0635

4/10; 0630

measure of the average amount of

Hgb within an RBC. little
information to other indications

measure of the average

concentration or percentage of Hgb
within a single RBC. can indicate
iron deficiency

indicate the variation of RBC size.

helps determine specific types of
anemia

Pt has anemia nos

Increased levels: macrocytic
anemia
Decreased levels: microcytic
anemia, hypochromic anemia
Assess for anemia
Increased levels: spherocytosis,
intravascular hemolysis-counter
adds free Hgb into count, cold
agglutinins
Decreased levels: iron-deficiency
anemia, thalassemia
Assess and monitor for anemia
Increased levels: iron-deficiency
anemia, B12 vitamin or folatedeficiency anemia,
hemoglobinopathies, hemolytic
anemias, posthemorrhagic anemia
Assess for anemia, assess for
nutrient deficiency, assess for signs
of bleeding

Platelet Count
LA8/2011

130-400

205

165

156

measures the amount of platelets in

the blood to determine how

Pt is anemic and taking Heparin

Elevated levels make it easier for
blood to clot. monitor for signs of

MPV

NRBC

Neutrophil Rel

Lymphocyte Rel

7.4-10.4

42-75

20-50

8.5

4/9; 0635

4/10; 0630

9.3

9.6

4/9; 0635

4/10; 0630

4/4; 0305

4/8; 0635

4/10; 0630

85.5 (H)

80.2 (H)

76.7 (H)

4/4; 0305

4/8; 0635

4/10; 0630

6.3 (L)

9.3 (L)

11.1 (L)

4/4; 0305

4/8; 0635

4/10; 0630

Monocyte Rel

2-14

6.2

5.4

7.5

Eosinophil Rel

0-8

4/4; 0305
1.7

4/8; 0635
4.4

4/10; 0630
4.1

4/4; 0305

4/8; 0635

4/10; 0630

5.1

0.7

0.6

4/4; 0305

4/8; 0635

4/10; 0630

Basophil Rel

LA8/2011

0-1

effectively a person's blood can

clot. increased number of platelets
the easier it is for a person to clot
Measure of the volume of a large
number of platelets. includes
mature and immature platelets

Calculates the number of RBCs

with nuclei. nRBC are indicative
of the production of new
erythrocytes. Though they are
normal in neonates, they are of
concern in adults. nRBC, or
normoblasts, can infer damage to
the bone marrow, stress or
presence of serious underlying
disease
fight infection. cells kill and digest
bacterial microorganisms within
the body

jugular distention, DVT, or

impaired skin integrity. Use
decompression socks on pt
Increased levels can result from a
massive hemorrhage
Assess for signs of bleeding or loss
of blood.
Increased levels: asplenia,
hypospelenia, hypoxia, severe
anemia, bone marrow replacement,
extramedullary hematopoiesis

Increased neutrophils indicate

infection in the body.
Monitor for signs of sepsis such as
hypotension and alterations in
temperature

Lymphocytes occur in two forms,

B cells and T cells. B cells produce
antibodies and T cells recognize
foreign bodies and process them
for removal. help to fight infection

Pt has aspiration pneumonia so

body is trying to fight the infection
Decreased levels: responses to a
bacterial or viral infection,
improper functioning of the bone
marrow, response to chemotherapy,
autoimmune disorders

aid in phagocytosis as well as

produce interferons

Pt has a bacterial infection due to

aspiration pneumonia
Present when body has a virus.
Treat pt for virus

present in allergic reaction

present in allergic reaction

Elevated levels: assess for signs of

allergic response, treat pt for
allergy, alter medication/treatment
as to prevent allergic reaction
Elevated levels: assess for signs of
allergic response, treat pt for
allergy, alter medication/treatment
as to prevent allergic reaction

Neurtophil Abs

Lymphocyte Abs

1.4-6.5

1.2-3.4

5.1

3.8

3.7

4/4; 0305

4/8; 0635

4/10; 0630

0.4 (L)

0.4 (L)

0.5 (L)

4/4; 0305

4/8; 0635

4/10; 0630

Monocyte Abs

0-0.8

0.4

0.3

0.4

Eosinophil Abs

0-0.7

4/4; 0305
0.1

4/8; 0635
0.2

4/10; 0630
0.2

4/4; 0305

4/8; 0635

4/10; 0630

4/4; 0305

4/8; 0635

4/10; 0630

130 (L)

146 (H)

147 (H)

4/3; 0340

4/9; 0635

4/10; 0630

Basophil Abs

Na

0-0.2

136-145

fight infection. cells kill and digest

bacterial microorganisms within
the body

Lymphocytes occur in two forms,

B cells and T cells. B cells produce
antibodies and T cells recognize
foreign bodies and process them
for removal

Increased neutrophils indicate

infection in the body.
Monitor for signs of sepsis such as
hypotension and alterations in
temperature
Decreased levels: responses to a
bacterial or viral infection,
improper functioning of the bone
marrow, response to chemotherapy,
autoimmune disorders

aid in phagocytosis as well as

produce interferons

Pt has a bacterial infection due to

aspiration pneumonia
Present when body has a virus.
Treat pt for virus

present in allergic reaction

present in allergic reaction

To evaluate and monitor fluid and

electrolyte balance and therapy

Elevated levels: assess for signs of

allergic response, treat pt for
allergy, alter medication/treatment
as to prevent allergic reaction
Elevated levels: assess for signs of
allergic response, treat pt for
allergy, alter medication/treatment
as to prevent allergic reaction
Monitor for signs of hyponatremia
(weakness, confusion, lethargy) and
hypernatremia (dry mucous
membranes, thirst, agitation,
restlessness, mania, convulsions).
-Drugs that can increase Na levels:
anabolic steroids, antibiotics,
carbenicillin, clonidine,
corticosteroids, cough medicines,
estrogens, laxatives, methyldopa,
oral contraceptives
-Drugs that can decrease Na levels:
diuretics, haloperidol, heparin,
NSAIDs, sodium- free IV fluids,
sulfonylureas, triamterene, tricyclic
antidepressants, vasopressin
Pt is NPO receiving NS in IV at a
rate of 10 mL/hr. This could cause
dehydration in the pt which could
increase the level of sodium

LA8/2011

Cl

3.5-5.1

98-107

3 (L)

3.2 (L)

4.1

4/3; 0340

4/9; 0635

4/10; 0630

94 (L)

101

106

4/3; 0340

4/9; 0635

4/10; 0630

Routinely evaluated for any type of

serious illness--important to
cardiac function. important in
neuron function, in preventing
muscle contraction, and the
sending of all nerve impulses. low
or elevated potassium can effect
brain functioning. affected by acidbase balance (acid elevates
potassium, bases lower potassium
can give an indiaction of acid-base
balance and hydration status

Monitor for hypokalemia

(decreased contractility of
smooth/skeletal/cardiac muscles-weakness, paralysis, hyporeflexia,
ileus, increased cardiac sensitivity
to digoxin, dysrhythmias) and
hyperkalemia (irritability, nausea,
vomiting, intestinal colic, diarrhea)
Pt take is on Lasix and takes it at
home as well.
Increased level: dehydration,
excessive infusion of normal saline
solution, metabolic acidosis, renal
tubular acidosis, cushing syndrome,
kidney dysfunction,
hyperparathyroidism, eclampsia
Decreased level: overhydration,
syndrome of inappropriate secretion
of ADH, congestive HF, vomiting,
chronic diarrhea, chronic
respiratory acidosis, salt losing
nephritis, addison disease, diuretic
therapy, hypokalemia,
aldosteronism, burns
Monitor hydration status, assess for
signs of heart failure, assess
pH/acid-base balance, monitor K
levels

CO2

LA8/2011

22-29

32 (H)

33 (H)

33 (H)

4/3; 0340

4/9; 0635

4/10; 0630

Assists in evaluating pH status and

of electrolytes. An indirect
measure of HCO3

Pt is hypokalemic. Pt RR was also

24 and she has pneumonia.
Therefore she can have slight
respiratory acidosis.
Increased level: severe vomiting,
high volume gastric solution,
aldosteronism, use of mercurial
diuretics, COPD, metabolic
alkalosis
Decreased level: chronic diarrhea,
chronic use of loop diuretics, renal
failure, diabetic ketoacidosis,
starvation, metabolic acidosis,
shock

Monitor I&O, administer

antiemetics, monitor for signs of
kidney failure, monitor acid-base
balance, monitor diet/meals

AGAP

Glucose

16

70-110

15

12

4/3; 0340

4/9; 0635

4/10; 0630

100

256 (H)

292 (H)

4/3; 0340

4/9; 0635

4/10; 0630

Evaluation of acid-base disorders.

used to attempt to identify the
potential cause of the disorder and
monitor therapy for acid-base
abnormalities

Glucose is regulated in the body by

a biofeedback mechanism and is
controlled by insulin and glucagon.
glucose levels are low after fasting
and increase after eating. glucose
levels are typically monitored in pt
with DM but glucose levels can
alter with stress, kidney failure,
and liver failure

Pt is taking Lasix and has

pneumonia/respiratory failure.
Therefore she is not exhaling the
proper amount of CO2
Increased level: lactic acidosis,
diabetic ketoacidosis, alcoholic
ketoacidosis, alcohol intoxication,
starvation, renal failure, increased
gastrointestinal losses of
bicarbonate, hypoaldosteronism
Decreased level: excess alkali
ingestion, multiple myeloma,
chronic vomiting or gastric suction,
hyperaldosteronism,
hypoproteinemia, lithium toxicity
Monitor ion levels, control diabetes,
assess for kidney failure,
administration of antiemetics
Increased levels: Diabetes
Mellitus-inadequate amount or
resistant insulin, acute stress
response, cushing syndrome,
chronic renal failure-glucagon is
metabolized by the kidneys loss of
this function causes glucose and
glucagon levels to rise, acute
pancreatitis, diuretic therapy,
corticosteroid therapy, acromegaly
Decreased levels: insulinomainsulin produced without regard to
biofeedback mechanism,
hypothyroidism, hypopituitarism,
extensive liver disease, insulin
overdose, starvation
Monitor for signs of hypoglycemia
(agitation, slurred speech,
confusion, hunger, faint) and

LA8/2011

hyperglycemia (diaphoresis, warm

skin, soft eyes, rapid pulse,
hypotension, fruity breath)

Ca

BUN

8.8-10.2

8-23

7.9 (L)

8.4 (L)

0.9

4/3; 0340

4/9; 0635

4/10; 0630

12

45 (H)

50 (H)

4/3; 0340

4/9; 0635

4/10; 0630

Evaluates parathyroid function and

Ca metabolism. used to monitor pt
with renal failure, renal
transplantation,
hyperparathyroidism, and various
malignancies

To assist in assessing renal

function and diagnosing disorders
such as kidney failure and
dehydration. Used to measure the
production and excretion of urea

Pt has diabetes mellitus and is using

a diuretic
Low levels of Ca are an indicator of
renal dysfunction.
Monitor for electrolyte imbalance,
dehydration, alkalosis, and acidosis.
Pt has many electrolytes that are not
in balance. on admission, there was
no indication of renal disease, but
the second set of serum testing on
4/9 has GFR values and increased
BUN that indicate worsening
kidney functioning
Increased levels indicate: acute
renal failure, chronic
glomerulonephritis, congestive
heart failure, decreased renal
perfusion, diabetes, gastrointestinal
bleeding, ketoacidosis,
hypovolemia, shock, urinary tract
obstruction
Decreased levels indicate:
inadequate dietary protein, high
carbohydrate diet, malabsorption
syndromes, pregnancy, severe liver
disease
-Symptoms of elevated BUN:
acidemia, agitation, confusion,
fatigue, nausea, vomiting, coma

Creatinine

LA8/2011

0.7-1.2

0.4 (L)

0.9

4/3; 0340

4/9; 0635

4/10; 0630

To diagnose and assess impaired

renal function

Pt has diabetes which could cause

an increase in BUN
Increased levels indicate: diseases
affecting renal function (urinary
tract obstruction, shock,
dehydration, CHF, atherosclerosis,
daibetic nephropathy), acromegaly,
gigantism

Decreased levels indicate:

debilitation, decreased muscle mass

BUN/Creat

GFR African
American

GFR Non-African
American

FiO2

Blood pH

15:1-24:1

>= 60

>= 60

30*

45*

56*

4/3; 0340

4/9; 0635

4/10; 0630

190*

66

74

4/3; 0340

4/9; 0635

4/10; 0630

156.9*

54.5* (L)

61.55*

4/3; 0340

4/9; 0635

4/10; 0630

21-100

30

7.35-7.45

4/4; 0504
7.53* (!)
4/4; 0504

To assist in assessing renal

function and diagnosing disorders
such as kidney failure and
dehydration. Used to measure the
production and excretion of urea
BUN and Creatinine often
evaluated together
GFR is a measure of kidney
function. GFR is the amount of
blood filtered through the
glomeruli per minute. if filtration
decreases, there is an increased
amount of waste product remaining
in the blood. Creatinine, a waste
product from muscles, can be used
to measure the approximate GFR.
GFR is a measure of kidney
function. GFR is the amount of
blood filtered through the
glomeruli per minute. if filtration
decreases, there is an increased
amount of waste product remaining
in the blood. Creatinine, a waste
product from muscles, can be used
to measure the approximate GFR.

Determines the proportion of

oxygen inhaled in combination to
other chemicals that constitute air
Inversely measures the amount of
hydrogen ion concentration in the
blood.

Assess for muscular atrophy, I&O,

hydration status, diet
Monitor I&O, hydration status, and
diet

High GFR- normal kidney function,

monitor urine and output, monitor
for
acute changes in renal function
Decreased GFR- kidney damage is
a priority assessment, amount of
urine decreases, HTN, urinate more
or less, feel itchy, tired, anorexia,
swelling or numbness in hands or
feet, muscle cramps.
High GFR- normal kidney function,
monitor urine and output, monitor
for
acute changes in renal function
Decreased GFR- kidney damage is
a priority assessment, amount of
urine decreases, HTN, urinate more
or less, feel itchy, tired, anorexia,
swelling or numbness in hands or
feet, muscle cramps.
This would indicate the beginning
of kidney failure.
Assess for capillary refill, cyanosis,
decrease tissue perfusion
decreased level: ketoacidosis,
lactic acidosis, severe diarrhea,
renal failure, respiratory failure
Alkalosis: pH is elevated
Respiratory- hyperventilation
Metabolic- sodium bicarbonate

LA8/2011

10

overdose, prolonged vomiting,

nasogastric drainage
Acidosis: pH is decreased
Respiratory- respiratory
depression, pulmonary disease
Metabolic- diabetes, shock, renal
failure, intestinal fistula

pCO2

35-45

32.5 (L)
4/4; 0504

pO2

75-100

134 (H)
4/4; 0504

Bicarbonate

None Stated

27
4/4; 0504

O2 Sat Calc

90-100

99
4/4; 0504

Partial pressure of carbon dioxide

in the blood. used as a
measurement of ventilation.

Indirect measure of O2 content of

the arterial blood. Measure of the
tension of O2 dissolved in the
plasma, determines the force of O2
to diffuse across the pulmonary
alveoli membrane Used to
determine the effectiveness of O2
therapy

A measure of the metabolic

component of the acid-base
equilibrium. regulated by the
kidneys. as bicarbonate increases,
so does blood pH

Used as an indication of the

percentage of hemoglobin
saturated with O2.

Pt is admitted with RR 24
breaths/min.
Decreased levels: faster, deeper
respirations; hypoxemia, pulmonary
emboli, anxiety, pain, pregnancy
Increased levels: decreased
respirations, can cause coma;
COPD, over sedation, head trauma,
overoxygenation in pt with COPD
Pt presented with RR 24. Also, has
anxiety
Decreased levels: pt who are
unable to oxygenate blood due to
diffusion difficulties, pt whom
venous blood mixes prematurely
with arterial blood, pt who have
underventilated and overperfused
pulmonary alveoli
Pt has increased respirations
causing increased O2 levels in the
blood
Increased level: chronic vomiting
or chronic high-volume gastric
suction, aldosteronism, use of
mercurial diuretics, COPD
Decreased level: chronic and
severe diarrhea, chronic use of loop
diuretics, starvation, diabetic
ketoacidosis, acute renal failure
Adequate levels of O2 sat allow for
adequate tissue perfusion
Assess capillary refill, monitor for
cyanosis

LA8/2011

11

Mod Allen Test

Positive

Positive

Used to measure arterial

competancy. indicates good or bad
blood flow

4/4; 0504

UA Color

UA Appear

UA Specific Gravity

UA pH

UA Protein

UA Leukocyte
Esterase
LA8/2011

Pale yellow to amber yellow

Clear

1.005-1.03

4.6-8

0-8

Negative

Yellow

Yellow

4/2; 0448

4/7; 1320

Hazy

Hazy

4/2; 0448

4/7; 1320

1.015

1.01

4/2; 0448

4/7; 1320

4/2; 0448

4/7; 1320

4/2; 0448

4/7; 1320

Negative

Negative

4/2; 0448

4/7; 1320

12

Changes due to the presence of

pigment urochrome (product of
bilirubin metabolism). due to the
concentration or urine and varies
with specific gravity. abnormal
color is result from a pathologic
condition or ingestion of different
foods/medicine
Cloudy urine- presence of pus
(necrotic WBC), RBC, bacteria,
certain foods (increased fat, urates,
phosphates
Measure of the concentration of
particles (including of wastes and
electrolytes) in the urine. used to
evaluate the concentrating and
excretory power of the kidneys
Indication of acid-base balance.
reflects the work of the kidneys.
useful in identifying crystals and
determine the predisposition of
kidney stones

Sensitive indicator of kidney

function. not usually present in
urine.

Used to detect leukocytes in the

urine. positive results indicate UTI

Positive: flushing within 5-15

seconds.
Negative: does not flush within 515 seconds
Assess capillary refill, assess for
acyanosis, assess for tingling or
numbness
Dark red- bleeding from the kidney
Bright red- bleeding inthe lower
urinary tract
Dark yellow- presence of
urobilinogen or bilirubin
Green- pseudomonas infection
Brown- eating rhubarb
Appearance should be clear because
there are no abnormalities in the
urine
Increased level: concentrated
urine, dehydration
Decreased level: dilute urine,
overhydration
Monitor hydration status
Increased: bacteria, UTI, fruits or
vegetables, acidosis, starvation,
dehydraion, diet high in meat
products
Decreased: alkalemia, associated
with calcium carbonate/calcium
phosphate/magnesium phosphate
stones
Hypoproteinemia: decreases the
normal capillary oncotic pressure
that holds fluid within the
vasculature and causes severe
interstitial edema
Proteinuria: indicator of renal
disease. can be indicator of
preeclampsia in pregnant women
Monitor for signs and symptoms of
UTI.

UA Nitrate

UA Glucose

UA Ketones

UA Bilirubin

UA Urobilinogen

UA Blood

UA WBC

None

Negative

Negative

4/2; 0448

4/7; 1320

Negative

Negative

4/2; 0448

4/7; 1320

Negative

Negative

4/2; 0448

4/7; 1320

Negative

Negative

Negative

Value Not Stated

4/2; 0448
Normal

4/7; 1320
Normal

4/2; 0448

4/7; 1320

Negative

Negative

4/2; 0448

4/7; 1320

Negative

Negative

Value Not Stated

Value Not Stated

5-10 (A)

Used as a screening test for UTIs.

(bacterias produce an enzyme
which can reduce nitrates to
nitrites. if dipstick reacts suggests
presence of bacteria in the urine)
Result of:
-excessively high glucose
concentration in the blood
-reduction in "renal threshold." (if
glucose levels are too high in
blood, kidneys will excrete glucose
in to urine to decrease blood
glucose concentration.)
Indicates massive fatty acid
catabolism.

Indication of liver disease and can

occur before clinical symptoms
Detection of liver diseases such as
hepatitis, cirrhosis, and conditions
associated with increased RBC
destruction
Low or absent in a person with
urine bilirubin and signs of liver
dysfunction, presence of hepatic or
biliary obstruction can be indicated
Used to detect hemoglobin in the
urine.
Vitamin C (ascorbic acid) can
produce falsely low or falsely
negative results. if RBC count is
normal in UA, but increased in
microscopic exam, test Vit C levels
Indicates infection or inflammation
somewhere in urinary tract

4/2; 0148

UA RBC

Value Not Stated

2-5
4/2; 0148

LA8/2011

13

Can indicate inflammation, injury,

or disease in the kidneys or
elsewhere in the urinary tract

Monitor for signs and symptoms of

UTI

Positive: uncontrolled diabetes,

hormonal disorders, liver diesease,
medications, pregnancy

Ketonuria: poorly controlled

diabetes, ketoacidosis associated
with
alcoholism/fasting/starvation/highprotein diets/ isopropanol ingestion
Monitor for signs of liver
dysfunction
Monitor for signs of hepatitis and
cirrhosis

Positive: diseases of the kidney and

urinary tract, trauma, medications,
smoking, strenuous exercise

Monitor for signs of UTI

Results indicative of UTI or Kidney
infection, but neither were stated in
the chart or H&P. She had a foley
but that was removed 4/6
Monitor for signs of kidney or
urinary dysfunction

UA Bacteria

Value Not Stated

3+

Urinary tract is sterile and will not

have microorganisms visible in the
urine sediment. presence of
bacteria indicate infection in the
urinary tract. (can start in bladder
and work its way up)

4/2; 0148

UA Squam Epith

Value Not Stated

5-10 (A)

Indicates the location of a

condition. (the type of cell narrows
location)

4/2; 0148

Monitor for signs of UTI or kidney

infection
Results indicative of UTI or Kidney
infection, but neither were stated in
the chart or H&P. She had a foley
but that was removed 4/6
Assess system from the location
specified
Results indicative of UTI or Kidney
infection, but neither were stated in
the chart or H&P. She had a foley
but that was removed 4/6

Procedure

Normal Impression

Impressions
(date & time)

Purpose

CXR, 1 View

Normal lungs and surrounding structures

4/2; 0005
Increasing airspace disease involving the
lower lobes bilaterally with vascular
congestion that is likely accentuated by
the low lung volumes

Provides a vast amount of information about

the heart, lungs, bony thorax, mediastinum, and
great vessels. can identify tumors,
inflammation of lungs, fluid accumulation, air
accumulation, fractures of bones in thorax or
vertebrae, diaphragmatic hernia, heart size,
calcification, and placement of central lines

4/2; 0600
1. PICC line catheter tip is in the
midsuperior vena cava
2. There is significant improved aeration
of the lower loves bilaterally with
persistent vascular congestion and
interstitial opacity
4/4; 0525
1.Improving edema
2. Persistant right lower lobe airspace
disease that could represent atelectasis,
asymmetric edema, or pneumonia
4/7; 0920
There is pulmonary vascular congestion.
No defined pneumonia

LA8/2011

14

Medication Allergies: Hydrogen Peroxide, Januvia, metFORMIN,

nateglinide, Prandin, repaglinide, starlix
Generic & Trade Name
Drug classification

Dose/Route Frequency
Rate of Administration

Action of Drug
Rationale

HMG-CoA Reductase
Inhibitors (statins)
Atorvastin (Lipitor)

20 mg PEG qBedtime

Inhibit an enzyme, 3hydroxy-3methylglutarylcoenzyme

A (HMG-CoA)
reductase, which is
responsible for
catalyzing an early step
in the synthesis of
cholesterol

Therapeutic: lipid-lowering
agent
Pharmacologic: HMG-CoA
reductase inhibitors

Significant
Side Effects
Rhabdomyolysis, abdominal
cramps, constipation, diarrhea,
flatus, heartburn, rash

Nursing Considerations related to patient

care and teaching
-if muscle tenderness develops, monitor CK
levels. med should be discontinued if CK
levels are >10 times the upper limit.
-avoid large amounts of grapefruit juice
during therapy; may increase risk of toxicity
-controls but does not cure elevated
cholesterol, should be used with diet
restrictions/exercise/no smoking.

*Home

Histamine H2 Antagonists
(Famotidine-Pepcid)
Therapeutic: antiulcer agent
Pharmacologic: Histamine H2
antagonist

20 mg=2 mL IV Push
q12h
Rate: over 2 minutes. (1
mL/min)

Use: lower total and

LDL cholesterol and
triglycerides, slightly
increase HDL.
Inhibits the action of
histamine at the H2receptor site located
primarily in gastric
parietal cells, resulting
in inhibition of gastric
acid secretion

Confusion, arrhythmias,
agranulocytosis, aplastic
anemia

*New

Furosemide (Lasix, Lasix

Soecial)
Pharmacologic: Loop Diuretics
Therapeutic: Diuretic
*Home

20 mg=2 mL IV Push
q8h
Rate: 4
mg/min=0.4mL/min

Uses: decreased
symptoms of
gastroesophageal reflux,
decreased secreation of
gastric acid. healing and
prevention of ulcers
Inhibits the reabsorption
of sodium and chloride
from the loop of Henle
and distal renal tubule.
increases renal excretion
of water, sodium,
chloride magnesium,
potassium, and calcium.
Uses: edema due to

LA8/2011

15

Blurred vision, dizziness,

headache, hypotension,
anorexia, constipation, diarrhea,
dry mouth, dyspepsia, nausea,
pancreatitis, vomiting,
increased BUN, excessive
urination, muscle cramps,
paresthesia, fever

-assess for epigastic or abdominal pain and

frank or occult blood in stool, emesis, or
gastric aspirate
-monitor CBC with differential periodically
during therapy.
- May cause increased serum transaminases
and serum creatinine.
-Smoking interferes with the action of
histamine antagonists
-avoid aspirin or NSAIDs.
-increased fluid and fiber intake can help to
prevent constipation

-Assess fluid status. monitor weight, intake

and output ratios, amount and location of
edema, lung sounds, skin turgor, and mucous
membranes.
-Monitor BP and pulse before and during
administration.
-Instruct pt to take as directed, take missed
doses ASAP; do not double doses
-Caution pt to change positions slowly to
minimize orthostatic hypotension.

heart failure, hepatic

impairment or renal
disease. Hypertension

Heparin (Hepalean, Hep-Lock,

Hep-Lock U/P)

5000 units (1mL) Subcut

q12h

Therapeutic: anticoagulant
Pharmacologic: antithrombotics

Insulin Glargine
(Long Acting)
(Lantus)
Therapeutic: antidiabetics,
hormones
Pharmacologic: pancreatics
*Home

30 Units Subcut
qBedtime
Peak: None
Onset: 3-4 Hours
Duration: 24 Hours

Potentiates the
inhibitory effect of
antithrombin on factor
Xa and thrombin. in low
doses, prevents the
conversion of
prothrombin to thrombin
by its effects on factor
Xa. Higher doses
neutralize thrombin,
preventing the
conversion of fibrinogen
to fibrin
Uses: prevention of
thrombus formation.
prevention of extension
of existing thrombi (full
dose)
Lowers blood glucose
by: stimulating glucose
uptake in skeletal
muscle and fat,
inhibiting hepatic
glucose production.
Inhibits lipolysis and
proteolysis, enhances
protein synthesis
Uses: control of
hyperglycemia in pt
with diabetes mellitus

LA8/2011

16

bleeding, heparin-induced
thrombocytopenia (HIT) (with
or without thrombosis), anemia

Hypoglycemia, lipodystrophy,
pruritus, erythema, swelling,
allergic reactions including
anaphylaxis

-Advice pt to contact health care provider if

gains more than 3 lbs in 1 day.
-Caution older pt about increased risk of
falls.
-Advice pt taking hypertension medication to
continue use even if feeling better and to
continue with additional therapies.
- assess for signs of bleeding and hemorrhage
-observer injection site for hematomas,
ecchymosis, or inflammation
-monitor aPTT (activated partial
thromboplastin time) and hematocrit.
-monitor platelet count every 2-3 days to
observe for heparin-induced
thrombocytopenia
-may cause hyperkalemia and increased AST
and AST levels
-do not take aspirin or NSAIDs while on
heparin
-caution pt to avoid IM injections

-assess pt for signs and symptoms of hypoand hyperglycemia

-monitor blood glucose q6 hr during therapy,
more often in ketoacidosis and times of
stress. A1C also be monitored ever 3-6 mo to
determine effectiveness
-use only insulin syringes to draw up dose. do
not mix insulin glargine or insulin determine
with any other insulin or solution, or use
syringes containing any other medicinal
insulin, use separate syringes and different
injection sites. solution should be clear and
colorless with no particulate matter. Instruct
pt on proper technique for administration.
-Explain to pt it controls disease not cure.
Emphasize importance of diet and regular
exercise. Instruct pt on signs and symptoms
of hypo- and hyperglycemia
-Advise to carry a source of sugar

Insulin (Rapid Acting)

(HumaLOG)
Therapeutic: antidiabetics,
hormones
Pharmacologic: prancreatics
*Home

High sliding scale q6h

<70- follow
hypoglycemia protocol
<140- 0 units
140-199- 3 units
200-249- 6 units
250-299- 9 units
300-349- 12 units
>349- 16 units
Peak: 1-2 Hours
Onset: Within 15
Minutes
Duration: 3-4 Hours

Nystatin (Mycostatin Topical)

Therapeutic: antifungals

100,000 Units/gram
Powder 1 Application
Topical Daily
(to groin and axillary)

Lowers blood glucose

by: stimulating glucose
uptake in skeletal
muscle and fat,
inhibiting hepatic
glucose production.
Inhibits lipolysis and
proteolysis, enhances
protein synthesis

Hypoglycemia, lipodystrophy,
pruritus, erythema, swelling,
allergic reactions including
anaphylaxis

Uses: control of
hyperglycemia in pt
with diabetes mellitus

Binds to fungal cell

membrane, allowing
leakage of cellular
contents

Diarrhea, nausea, stomach pain,

vomiting, contact dermitits,
stevents-johnson syndrome

*New

Piperacillin/Tazobactam
(Zosyn)

3.375 mg=15 mL IVPB

q8h-int over 4 hours
Rate: 3.75 mL/hr

Therapeutic: anti-infectives
Pharmacologic: extended
spectrum penicillins
*New

Sodium chloride (NaCl 0.9%)

LA8/2011

250 mL over 25 hr
Rate: 10 mL/hr

Use: fungistatic or
fungicidal action
Binds to bacterial cell
wall membrane, causing
cell death. spectrum is
extended compared with
other penicillins.
inhibits beta-lactamase,
an enzyme that can
destroy penicillins
Use: death of
suscepitble bacteria
Provide pt with fluids

17

Seizures, pseudomembranous
colitis, diarrhea, stevensjohnson syndrom, toxic
epidermal necrolysis, rash, pain,
phlebitis at IV site

-assess for symptoms of hypo-and

hyperglycemia. monitor body weight
periodically. assess pt for allergic rxns.
-may cause decrease serum inorganic
phosphate, magnesium, and potassium levels.
-monitor blood glucose q6hr during therapy
more often in ketoacidosis and times of
stress. A1C may also be monitored every 3-6
mo to determine effectiveness.
-clarify ambiguous orders. check type, dose,
expiration date with another licensed nurse.
do not interchange insulins without
consulting health care professional.
-use only insulin syringes to draw up dose.
store vials in refridgerator. do not use if
cloudy, discolored, or unusually viscous.
-Explain to pt it controls disease not cure.
Emphasize importance of diet and regular
exercise. Instruct pt on signs and symptoms
of hypo- and hyperglycemia
-Advise to carry a source of sugar
-Advise pt to contact health care provider if
nausea, vomiting, or fever develops, if unable
to eat regular diet or if blood glucose levels
are not controlled.
- inspect oral mucous membranes before and
freuqently throughout therapy. increased
irritation of mucous membranes may indicate
need to discontinue medication
-advise pt to report increased irritation of
mucous membranes or lack of therapeutic
responses
-assess for infection. obtain culture and
sensitivity.
-Ensure pt has no allergy to penicillin
-caution pt to notify HCP if fever and
diarrhea persist
-observe for s/s of anaphylaxis.
-assess skin rxns

-prevent dehydration in pt

*New
Hydrocodone/ acetaminophen
(Norco)

Continuous Infusion
325mg-7.5mg G-tube
q4h PRN

Therapeutic: allergy, cold,= and

cough remedies, opioid
analgestics
Pharmacologic: opiod
agonsits/nonopiod analgesic
combinations

Alter the perception of

and a response to
painful stimuli while
producing generalized
CNS depression.
suppress the cough
reflex via a direct
central action
Uses: mild to moderate
pain

Confusion, dizziness, sedation,

euphoria, hallucinations,m
headache, unusal dreams,
blurred vision, dipolpia, miosis,
respiratory depression,
hypotension, bradycardia,
constipation, dyspepsia, nausea,
bomiting, urinary retention,
sweating, physical dependence,
psychological dependence,
tolerance

Binds to receptors in
airway smooth muscle
to increase levels of
cAMP which inhibits
the phosphorylation of
myosin and decreases
intracellular calcium.
Relaxes smooth muscle

Nervousness, restlessness,
tremor, headache, insomnia,
hyperactivity in children,
paradoxical bronchospasm,
chest pain, palpitations, angina,
arrhythmias, hypertension,
nausea, vomiting,
hyperglycemia, hypokalemia

*New

Albuterol-Ipratropium
(DuoNeb)

3 mL aerosol solution,
nebulizer RT q4h PRN

Therapeutic: bronchodilators
Pharmacologic: adrenergics
*New

Uses: shortness of
breath, wheezing

Glucose (D50 syringe)

12.5 mg=25 mL IV push

PRN

Use: hypoglycemia

Hyperglycemia

Inhibits salivation and

excessive repiratory
secretions when given
preoperatively. reverses
some of the secretory
and vagal actions of

Headache, nasal congestion,

tachycardia, dry mouth,
flushing

*New

Glycopyrrolate (Robinul)
Therapeutic: antispasmodics
Pharmacologic: anticholinergics
*New
LA8/2011

1 mg PO TID PRN

18

-Asses BP, pulse, and respirations. if RR is

<10/min, assess level of sedation.
-assess bowl function routinely to prevent
constipation.
- may increase plasma amylase and lipase
concentrations
-May be administered with food or milk to
minimize GI irritation
-advise pt to avoid activities that require
alertness
-advise pt to cough and reposition every 2 hrs
to prevent acetlectasis
-good oral hygiene, frequent mouth rinses,
and sugarless candy/gum can help to
decrease dry mouth
-Assess lung sounds, pulse, BP. Note
amount, color, and character of sputum
produced.
- may cause decrease in serum potassium
concentrations with nebulization or higher
than reccommended doses
-Have pt contact doctor if does not relieve
SOB. Have pt prime unit with 4 sprays before
using and to discard after 200 sprays
-Caution pt to avoid smoking and other
respiratory irritants
-Instruct pt to use albuterol first if have other
inhalants and to wait 5 min to elapse before
using other inhalants. Have pt rinse mouth
between each inhalation dose to prevent dry
mouth
-Quickly increases blood sugar
-Administer if FSBG <70
-Monitor for signs and symptoms of
hypoglycemia (Emotional changes, faint,
dizziness, fatigue, hunger, nervousness,
tremors, cold, clammy skin, headache, visual
changes, unsteady gait, slurred speech)
- assess HR, BP, and RR before and
periodically during parenteral therapy.
-monitor I&O. may cause urinary retention.
-assess pt routinely for abdominal distention
and auscultate for bowel sounds
-may cause dizziness or blurred vision. avoid

cholinesterase inhibitors
used to treat
nondepolarizing
muscular blockade.
adjunctive management
of PUD.

Potassium Supplements
(K-dur 20)
Therapeutic: mineral and
electrolyte
replacements/supplements
*New

K level:
3.8-3.9- 20 mEq
3.5-3.7- 40 mEq
3-3.4- 40 mEq,4h later
20 mEq (recheck
potassium level 4h after
second dose)
<=2.9- NOTIFY
PHYSICIAN. 40
mEq,4h later 40 mEq
(recheck potassium level
4h after second dose)

PEG PRN

Use: increase oral

secretions
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
secreations, renal
function, tissue
synthesis, and
carbohydrate
metabolism

driving or other activities that require

alertness until response to med is known.
-avoid extreme temperatures. medication
decreases ability to sweat and may increase
risk of heat stroke.
-notify HCP if eye pain or sensitivity to light
occur.

Confusion, restlessness,
weakness, arrhythmias, ECG
changes, abdominal pain,
diarrhea, flatulence, nausea,
vomiting, GI ulceration,
stenotic lesions, irritation at IV
site, paralysis, paresthesia

Uses: hypokalemia

KCl
Therapeutic: mineral and
electrolyte
replacements/supplements
*New

LA8/2011

Liquid PRN
20 mEq=15mL
K level:
3.8-3.9- 20 mEq
3.5-3.7- 40 mEq
3-3.4- 40 mEq,4h later
20 mEq (recheck
potassium level 4h after
second dose)
<=2.9- NOTIFY
PHYSICIAN. 40
mEq,4h later 40 mEq
(recheck potassium level
4h after second dose)

Maintain acid-base
balance, isotonicity, and
electrophysiologic
balance of the cell.
activator in many body
functions
Use: Potassium
Replacement

19

Arrhythmias, abdominal pain,

diarrhea, flatulence, nausea,
vomiting

-assess for signs and symptoms of

hypokalemia (weakness, fatigue, U wave on
ECG, arrhythmia, polyuria, polydipsia) and
hyperkalemia
-monitor pulse, BP, and ECG periodically
during IV thearpy
-monitor serum potassium before and
periodically during therapy. monitor renal
function, serum bicarbonate, and pH
-avoid salt substitutes or low-salt milk or
food. read food labels to avoid excessive
potassium intake
-encourage compliance with reccommended
diet
-pt is to report dark, tarry, or bloody stools;
weakness; unusual fatigue; or tingling of
extremitites. notify health care provider if
nausea, vomiting, diarrhea, or stomach
discomfort persists. dose may need
adjustment
-HOLD IF SERUM CREATININE > 2
- assess for signs and symptoms of
hypokalemia (weakness, fatigue, U wave on
EKG, arrhythmia, polyuria, polydipsia) and
hyperkalemia.
-monitor serum potassium. monitor renal
function, serum bicarbonate, and pH.
determine serum magnesium level if pt has
refractory hypokalemia. monitor serum
chloride.
-monitor for symptoms of toxicity
(slow/irregular heartbeat, fatigue, muscle
weakness, paresthesia, confusion, dyspnea,
peaked T waves ,depressed ST segment,
prolonged QT segments, widened QRS
complex, loss of P waves, and cardiac

arrhythmias)
-emphasize correct method of administration
-instruct pt to avoid salt substitutes or lowsalt milk or food.
-inform pt on sources of dietary potassium
-instruct pt to report dark, tarry, or bloody
stools, weakness, unusual fatigue, or tingling
of extremities. notify HCP if nausea,
vomiting, diarrhea, or stomach discomfort
persists

IVPB PRN
Rate- over 1 hour
3.8-3.9- 10 mEq- 2 doses
3.5-3.7- 10 mEq- 3 doses
3-3.4- 10 mEq- 4 doses
<=2.9- NOTIFY
PHYSICIAN. 10 mEq- 5
doses, recheck
postssium levels after
last dose

CONCEPT MAPPING
ND #1: Ineffective Airway
Clearance
Data to support: pt on ventilator,
tracheostomy, pneumonia
(excessive secretions)

ND #2: Impaired Gas Exchange

Data to support: Rx for Duoneb (bronchodilator,
will increase surface area), ventilator, hx of
pneumonia, low pCO2 in the blood, high pO2 in
the blood, low lung volumes, RR 24
(high/hyperventilation)

ND #4: Impaired Skin

Integrity
Data to support: pt bed
bound, connected to
ventilator, low Hgb/Hct,
NPO, pt has 4 pressure
ulcers and a skin tear,
body flaccid

Chief Medical Diagnosis: Pneumonia,

Respiratory Failure
Priority Assessments: Airway, Breathing,
Circulation, Braden Scale, Morse Scale, Skin

6. Discharge
-Placement in nursing facility
-Increased respiratory status
-Improvement or eradication of
infection
LA8/2011

20

7. Pt Education
- Teach her importance of
continued independence.
(continue doing as much ADL as
possible)

ND #3: Risk for ineffective

tissue perfusion
Data to support: anemic, using
ventilator, decreased Hgb/Hct,
Rx DuoNeb, decreased lung
volume, diabetes mellitus

ND #5: Risk for

Infection/Infection
Data to support: Multiple
insertion sites (PICC, G
tube, tracheostomy),
mucus secretions can pool
in airways, high
neutrophil count, low
lymphocyte count, hazy
urine with
WBC/Bacteria/Squamous
Epithelium, Rx Zosyn, Rx
Nystatin

Concept Mapping
Patient Response
1. ND/Nursing Care: Ineffective Airway Clearance
Suction tracheostomy
Assess changes in mental status

Reposition patient to be high up in the bed

Assess for changes in HR and BP

TEACH pt about the necessity of suctioning

2. ND/Nursing Care: Impaired Gas Exchange
Assess lung sounds

Monitor for effort of breathing

Administer 30% oxygen via ventilator

Position head of bed at 45 degrees for optimal

TEACH patient when we administer DuoNeb as PRN treatment

3. ND/Nursing Care: Risk for Ineffective Tissue Perfusion
Assess radial and pedal pulses

Assess warmth of skin

Assess color of skin

Assess capillary refill and nails for clubbing

Suctioned 5mLthin white sputum from airway

Pt showed no alteration in mental status
throughout the day.
Pt had better chest expansion.
at 0715, HR 61 BP 107/60. at 1200, HR 61 BP
112/74

Pt had coarse lung sounds in the upper lobes,

and coarse sounds and crackles in the lower
lobes.
Chest expansion symmetrical and nonlabored,
with use of ventilator on assist/control.
O2 saturation remained at 100%
Pt most comfortable with head of bed raised and
head propped up on two pillows.

Right and left radial pulses were 2+, right and

left pedal pulses were 1+
Skin was warm and dry
Color was appropriate to ethnicity with no signs
of cyanosis
I tried to assess the cap refill but the nails were a
brown color making it hard to assess. I then
looked to ensure that the nails were not clubbing.
the nails had a nail base-angle of 165 degrees.

TEACH pt signs of hypoxia (tachycardia, cyanosis,

tingling in extremities, anorexia, cool skin)
4. ND/Nursing Care: Impaired Skin Integrity
Application of Nystatin

LA8/2011

21

Applied Nystatin in axilla, groin, and pelvic

areas

Reposition q2h

Application of barrier cream

Assess amount of shear and fiction

0700 pt was in a supine position 0917 place pt in

right side lying 1058 pt place in supine position
1204 pt placed in left side lying. 1400 pt put
supine
Pt had many small excoriations to buttock, did
not like being moved but area fully covered.
Kept pt high in the bed with the head raised at
45 degrees. Kept the sheets with few wrinkles
and straightened them out as needed. Ensured
trach neck ties did not put too much force of pt
neck

TEACH pt why it is important to reposition

to prevent skin breakdown
5. ND/Nursing Care: Risk for Infection/Infection
Administration of Zosyn

Assess insertion points (G tube, PICC line, Trach)

Monitor for changes in WBC level

Monitor the appearance of pt urine

TEACH pt of signs of infection (fever,
chills, anorexia, redness around insertions)

IVPB hung at 0904, administration completed at

1304. bag removed at 1316
Area around PICC and trach clean and dry with
no signs of redness or swelling. G tube was
pushed too far out and leaked around
surrounding area. There was blood on the
dressing. the skin around the insertion point was
excoriated and bleeding.
On 4/9 at 0635, WBC level was 4.9. on 4/10 at
0630,WBC level was 4.8
4/10 pt produced clear, yellow urine

*I'm unsure of how the patient really responded to my teaching, especially since she was nonverbal and spoke another
language. I know that she was uncomfortable and upset whenever we suctioned or repositioned her so tried to reassure her
why.

LA8/2011

22

SOAP NOTE:
S- Seventy-two year old female patient admitted on 3/31/2014 presenting with diagnosis
of aspiration pneumonia and respiratory failure. She has a related diagnosis of CVA
(leaving her bedbound and nonverbal), Diabetes Mellitus, Seizure, TIA, Anemia,
Dyspnea, and Thyroid dysfunction. Pt is alert, but orientation is not measurable due to
inability to speak. This patient has a history of CAD, hyperlidemia, convulsions, and
hypertension. Her home medications include Atorvastatin, Lasix, Lantus, and
HumaLOG.
O- Pt is calm but is highly displeased when interrupted. She dislikes being moved or
suctioned. Vitals taken at 0715 were T 36.3 HR 61 RR 12 BP 107/60 SpO2 100% with
ventilator at 30% FiO2. Pt unable to state pain but grimaces and frowns when moved,
suctioned, or provided with tracheostomy care. She is a 7/10 according the Wong-Baker
scale. Small amounts of thin, white sputum were suctioned from the patients trach tube at
approximately 0736.
HEENT- The patient did not have corrected visual acuity. she did not have any foreign
objects in her ears, nose, or ears. She did not have epitaxis. Pt had dry mouth with small
amounts of sputum with no other noted abnormalities of the mouth or throat.
Neuro- Patient's body was completely flaccid and she was incapable of speaking. She
was alert and eyes would move according to stimulation of voice and movement.
CV- Pt has brisk capillary refill and no visible signs of edema. The pt has a normal rate
and rhythm with clear S1/S2 sounds. There are no murmurs, clicks, or gallops
Resp- Pt has coarse lung sounds in the apices and crackles in the bases. Respirations are
managed by ventilator on assist/control which is set to 30% FiO2.
GI- Pt is on a tube feeding diet of osmolite 1.2. Abdomen is soft and rounded with no
distention or tenderness. Bowel sounds are active in all four quadrants. There is no pain
or masses on palpation. LBM was 4/9/14 at 2300.
GU- Pt is incontinent and requires intermittent straight catheterization q6h. The bladder
is not visibly distended and pain or fullness is not indicated by the patient. At 1304
straight catheterization drained 350 mL of clear, light yellow (straw?) colored urine.
Musculoskeletal- pt is completely flaccid and has not range of motion in any extremity.
Skin: Pt has a PICC line, G-tube, and tracheostomy. The PICC line and tracheostomy
are clean, dry, with no inflammation or redness. G-tube is was pushed too far away from
the skin so stomach acid leaked to area around it leaving it excoriated and bleeding. She
is covered in bruises and areas of ecchymosis. Skin is otherwise of appropraite color and

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has reduced turgor. She has stage 1 pressure ulcers to the left groin, left and right kee,
and coccyx. Patient has a stage 2 pressure ulcer on the right buttock that was cleaned
with soap and water and covered using a barrier cream to protect from further
rubbing/friction. Skin is clean, warm, and dry.
A- Pt has ineffective airway clearance, impaired gas exchange,and risk for impaired
tissue perfusion all related to respiratory failure and pneumonia
P- Continue to monitor the amount, color, and consistency of sputum suctioned. Assess
lung sounds for changes. Monitor for changes in tissue perfusion and circulation.
Continue to assess pt mental status and anxiety. Monitor insertion sites for signs of
infection. Ensure that patient is repositioned every two hours.

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