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Laboratory Values: Complete the table with applicable lab values, for the
results/trend indicate if value is increased or decreased from previous result
TEST NORMAL VALUES DATE/TIME RESULT/ REASON FOR ABNORMAL VALUE AND
RECENT EFFECT OF ABNORMAL VALUE
TREND (POTENTIAL SYMPTOMS)
White blood cells 3.6-10.6 11/07/2017 8.0 Within Range
(WBC) 0533
Red blood cells (RBC) 4.50-5.20 11/07/2017 3.58 Low Low, can be because of cells being under
0533 Stress with MI, and there was an increase
of cells lysis. There is a decrease of RBC
production.
Hemoglobin (Hgb) 13.5-17.5 11/07/2017 11.3 Low Low, because there is low count of RBCs,
0533 and a decrease production of RBCs.
Hematocrit (Hct) 41.0-53.0 11/07/2017 33.6 Low Low, because the ratio of red blood cells
0533 to the rest of the plasma is low. Because
of the lysis of cells or decrease
production of RBCs.
TEST NORMAL VALUES DATE/TIME RESULT/ REASON FOR ABNORMAL VALUE AND
RECENT EFFECT OF ABNORMAL VALUE
TREND (POTENTIAL SYMPTOMS)
Platelets 150-400 11/07/2017 153 Within Range
0533
Creatinine .77-1.35 11/07/2017 0.66 Low Low, from his lower muscle mass and
0533 might have a low protein diet, he is also
aging (75).
Troponin Lower then 0.01 ng/mL 11/04/17 26 High High, he just had a heart attack. This
value is normally high following a heart
attack and is a great indicator to confirm
heart attacks.
B-natriuretic peptide >100 pg/mL 11/02/17 293 High High, because he has heart failure. This
(BNP) 2100 lab helps indicate heart failure and helps
with diagnosis.
Other Labs
Allergies:
Allergies: NKDA Type of Reaction: ------
Standards of Care:
NO YES INTERVENTIONS ORDERED
DVT prophylaxis X Heparin
Stress ulcer prevention X Change positions Q 2 hours
Ventilator-associated pneumonia (VAP) X
Intake/Output:
Diet Order: NDD2 Restrictions: No Precautions: Sit at 90 Gag Reflex Intact: No, needs
(National Dysphagia Diet) thin liquids degree position in chair supervision during meals.
when eating.
Appetite (good, fair, poor): Breakfast % Lunch % Dinner %
Good 100% 75% N/a
Total Oral Fluid Intake: Total IV Fluid Intake: Total Output: 950
1281.7 N/a
Intravenous Therapy:
IV Fluid: N/a Type of Solution: N/a IV rate: N/a Indication: N/a
Elimination:
Last bowel movement: 11/7/12
Large, loose, brown.
Constipation YES NO
Diarrhea YES NO
Flatus YES NO
Incontinence-bowel YES NO
Urinary hesitancy YES NO
Urinary frequency YES NO
Burning YES NO
Incontinence-urinary YES NO
Unusual odor YES NO
Activity:
Type of activity ordered: Ability to walk (gait): Shuffled Morse Falls scale score: 35
As tolerated with bed mobility steps, able to support self for
training, and a one person limited amounts of time. Needs
transfer assist. assistance.
Neurological:
Glasgow Coma Assessment *Describe any abnormalities in box below: 15
Eye opening response Score: 4 Spontaneously
Verbal response Score: 5 A&O
Motor response Score: 6 Obeys commands.
Pupil Assessment
Right pupil size Size: 3mm
Left pupil size Size: 3mm
PERRLA YES: X NO:
Cardiovascular:
Pulses (radial, pedal) palpable, equal, strong YES NO
Normal heart tone (S1, S2), regular YES NO
Capillary refill (<3 seconds all extremities) YES NO
Extremity temperature warm to touch, YES NO
bilateral upper and lower extremities
Edema presence YES NO Specify location and degree 0-4 scale
Ventilation
Is patient on ventilator? YES NO
Ventilator mode N/a
FiO2 N/a
PEEP N/a
Rate N/a
Tidal volume N/a
Type of airway tube N/a
Indication N/a
Nausea YES NO
Vomiting YES NO Description:
Fall risk YES NO Specify rationale: Has IVs, catheter and muscle
weakness.
Skin:
Skin dry, intact, color within patient norm YES NO
Mucous membranes moist YES NO
Evidence of skin breakdown YES NO Specify location:
Braden Score: 20
Pain
Pain Score __2_____ out of 10 (10 being severe pain, 1 minimal pain)
Characteristics A dull ache around his chest area.
Onset Occurs with breathing and some movement. Along with the occasional cough.
Medication List: For all PRN and scheduled meds please include the following
Trade name
Generic name
Mechanism of action (how does the drug work)
Dose/route/frequency
Indication for the drug (why is the patient receiving the medication)
Major side effects
Nursing implication
Special precautions
Atorvastatin: Lipitor
MOA: Stops HMG-CoA reductase and helps with cholesterol biosynthesis.
Dose: 40 mg Oral tab Daily at bedtime
Major Side Effect: Insomnia, abdominal pain, musculoskeletal pain, rash, nausea, diarrhea.
Nursing implications: May increase ALT, AST and CK levels. Avoid drinking grapefruit juice.
Special Precautions: Monitor stools, and maintain balanced input and output.
PRN
Heparin Flush
MOA: Is an anticoagulant, deactivates thrombin and prevents blood from clotting.
Dose: heparin flush 10 units/ml IV solution, 30 units = 3 ml IV push, injectable. As directed
PRN
Indication: To maintain line patency.
Major Side Effect: Hyperkalemia, hemorrhage, overly clotting time prolonged
Nursing Implication: Watch lab values, and liver function. Take into account which line to
draw blood from, it can ruin the line.
Special Precaution: Educate patient to watch for bleeding.
Cardiac Arrest with a right bundle branch block and V-fib: Cardiac arrest is a sudden onset of
cessation of cardiac activity, in this case it was caused by v-fib, which can have happened
because an artery became blocked. His history of past hyperlipidemia could have caused this.
This means that the ventricles, the bottom chambers of the heart twitch but doesn’t fully pump
blood. This can lead to other complications if the heart decides to clot and travel to the heart or
brain. The right bundle branch block happens when the electrical conduction is blocked and the
right ventricle doesn’t contract but the left bundle branch still works normally.
Ischemic Cardiomyopathy: Is a problem with the heart muscle, they either become thickened
or stiff and takes on a much larger appearance. This makes it harder to pump blood through the
heart and to the rest of the body. This can lead to heart failure and can be caused from a heart
attack because blood can’t reach the muscle to oxygenize them or from coronary artery
disease, because the vessels are to narrow for the blood to travel to the muscles.
Heart Failure: The heart is able to fill or eject blood and this decrease the cardiac output and
can lead to fluid building up in the lungs, heart and body. Right-sided heart failure can come
from ineffective right ventricular contractions. Left sided heart failure is caused by ineffective
ventricular contraction, which leads to pulmonary congestion and edema. Causes can be from
anemia, arrhythmias, emotional stress, atherosclerosis with myocardial infarctions and
infections.
CAD: Can be caused by increased level of low-density lipoprotein, it can irritated or damaged
the coronary vessel. These streaks can damage the protective barrier and form fatty streaks.
Then the fatty substance is covered in smooth muscle cells and can stimulate calcium
depositions. These fatty deposits narrow the vessels, making it harder for blood to move from
or to the heart or to the body. These plaques can rupture and can travel to the lungs or brain,
leading to a pulmonary embolism or stroke.
References:
Davis's Drug Guide for Nurses 15th Edition by April Hazard Vallerand PhD RN FAAN (Author),
Cynthia A. Sanoski BS PharmD FCCP BCPS (Author)
Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th Edition.