Lone Star College - North Harris

Associate Degree Nursing Program

Name of Student: Michael Tellez Date(s) of care: 10/6/10

PRECLINICAL Vitals Signs List the Medical Diagnoses Given

(To be completed prior Clinical)

1. Clinical objectives (from syllabus)

8 am
Bp:117/66 Pulmonary edema, SOB, CRF
HR: 89
Resp: 18
Temp: 98.1

12 pm
2. Personal Clinical Goals Bp: 106/57
HR: 89
Resp: 20
Temp: 98.4

4 pm
Bp: 100/56
HR: 8
Resp: 20
Temp: 98.1

CLINICAL WORKSHEET

42315791.doc
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SECTION 1:
Nursing Diagnosis #1With R/T and AEB
Decreased cardiac output,
R/t: Altered hear rate, altered heart rhythm,
altered contractility
AEB: BP/HR/ Cardiac index/Activity
tolerance/ Heart rhythm/ Heart sounds/
Peripheral edema
Nursing Diagnosis #2With R/T and AEB
Fluid volume excess
R/t: compromised regulatory mechanism;
excess fluid intake; excess sodium intake
AEB: peripheral edema, neck Vein
distention/adventitious breath sounds
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Clinical Worksheet
Nursing Diagnosis #3With R/T and AEB
Ineffective breathing pattern
R/T: obesity, pain, perception impairment,
respiratory muscle fatigue
AEB: respiratory rate, respiratory rhythm, depth of
inspiration, ease of breathing
 Clinical Worksheet

SECTION 2:

1. Include a brief summary of the reason your client was admitted

2. Including the date of admission
3. Past Medical and Surgical History
4. Describe the pathophysiology of each of your client’s medical diagnoses/problems.
***Be sure you describe the signs and symptoms that your client exhibits for each of the medical diagnoses***

64 yr old African American female w/ past med hx of diabetes, Hypertension, end-stage renal disease, bilateral amputation of
legs. Admitted on 10/3/10 due to SOB. Pt was found to have Pulmonary edema, and fluid overload. Pt was also found to have
a positive troponin, possibly secondary to renal failure

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Pt name:

Allergies: N/A

Admit Date: 10/3/10

C/O: SOB

History: COPD, GERD, CAD HTN, Depression

Assessment

Neurovascular: alert orientated x 3, denies any pain, strength is equal bilaterally in upper extremities

Pulmonary: respiratory is tachypnea, crackles in both lungs, complained of SOB at rest, bed was raised to 90 degree

Cardiac: S1, S2 heard/tachycardia, cap refill < 3 sec. Pulse +2 bilaterally,

Gastrointestinal: bowel sounds present x 4, last BM was at 0815, abdomen soft

Geriurinary: Dialysis pt, fistula noted in Left arm, reports to dialysis: mon, wed, and fri.

Skin: appears fragile, thin, w/ poor turgor, feels dry, color is normal, temp is warm, asculated and palpated fistula (brurt/thrill heard)

PIV: R hand

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Skills Performed : assisted pt with feeding and drinking, movement of pt, helped admin transdurmal patch

Skills Observed: hanging of blood, admin of iv pain meds, watch d/c of foley

Reflection of day/thoughts/questions/concerns: oversell the day went well, the nurse was very helpful in explaining what she was doing to the pt.

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**Remember to keep Client Tracker up to date**

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LABS:
Write Down the Main Labs Here and any other Pertinent Labs that would relate to Patient if not listed here

Lab Level – Indicate if H or L Rational if Abnormal Related to Patient

CBC (Complete Blood Count)

WBC 7.8

RBC 3.72

HEMOGLOBIN 11.4-L Due to FVE, diluting the serum

HEMOCRIT 35.0-L Due to FVE, diluting the serum

PLATELET COUNT NA

BMP (Basic Metabolic Panel)

GLUCOSE 60-Low Due to the fact she did not eat before she went to dialysis

CALCIUM 9.0

ALBUMIN

SODIUM 135

POTASSIUM 4.4

CHLORIDE 97-L

KIDNEY TEST

BUN (BLOOD UREA NITROGEN) 57-H 7Due to kidney failure

CREATININE 6.50-H Due to kidney failure
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LIVER TEST NA

ALP NA

ALT NA

AST NA

LIPID PROFILE NA

CHOLESTROL NA

HDL NA

LDL NA

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SECTION 3: NURSING PROCESS
*** Select 1 out of the 3 Nursing Diagnosis you written and expand on it here. Only One***
ASSESSMENT
Subjective Data:
Pt complained of SOB at res,
very dazed and confused,
Objective Data:
(include pertinent lab results
and results of diagnostic data)
SOB, BUN High, Creatine
High, H&H low, Chlorine low
NURSING
DIAGNOSIS
(INCLUDE R/T and AEB)
Fluid volume excess
R/t: compromised
regulatory mechanism;
excess fluid intake; excess
sodium intake AEB:
peripheral edema, neck
Vein
distention/adventitious
breath sounds
Clinical Worksheet
PLAN INTERVENTIONS EVALUATION
(At least 4 Interventions)
(INCLUDE AT LEAST ONE
(INCLUDE AT LEAST ONE INTERVENTION WHICH
SHORT TERM AND ONE DEALS WITH PATIENT (EVALUATE EACH OF THE
LONG TERM GOAL) TEACHING) CLIENT GOALS)
Monitor location and extent Pt was on strict I&Os and
of edema adhered to the goal very
Short Term: well
Monitor daily wts.
Pt will have balance Pt was able to have less
I&Os for 24 hours Monitor I&Os crackles in lungs at the end
of shift.
Monitor Vital signs
Listen to lungs for crackles
Long Term: Teach pt about a low
sodium diet
Pt will maintain clear
lung sounds with no
evidence of dyspnea or
orthopnea for the entire
length of stay at hospital
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SECTION 4: MEDICATIONS LOG

MEDICATION(Includ CLASSIFICATION INDICATIONS(SPECIFIC PRECAUTIONS/SIDE NURSING ASSESSMENT DATA

e both brand & generic & Mechanism of TO CLIENT NEEDS) EFFECTS (SPECIFIC TO CLIENT NEEDS)
names, Action
dosage/frequency, &
route.)
Generic Name: Classification: May decrease absorption of Diarrhea, flatulence, Effectiveness of med: Seemed to be
Protonix Proton pump ampicillin, iron salts, abdominal pain, HA working fine
Brand Name: inhibitor increases INR with Assessment for possible side effects:
Pantoprazole sodium warfarin, may cause false none reported
Dosage:40 mg Action: positive THC
Frequency: everyday Gastric acid pump
Route:PO inhibitor; gastric
acid is decreasing by
inhibiting the
hydrogen

Generic Name: Classification May cause potentiat N, D, constipation, Effectiveness of med: pt responded
Glucotrol XL Hormone; hypoglycemic actions, hypoglycemic, hunger, GI well to meds
Brand Name: antidiabetic, Action: thiazides may antagonize distress Assessment for possible side effects:
Glipizide Directly stimulates hypoglycemic effects none reported
Dosage: 2.5X2=5mg fxn pancreatic beta
Frequency: 2 cells to secrete
tabs,Once a day insulin, leading to an
Route: PO acute drop in blood
glucose

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Generic Name: Classification: ACE Monitor serum sodium and Dizziness, HA, lethargy, Effectiveness of med: Pt reported
Lisinopril inhibitor, serum potassium, monitor fatigue, drowsiness, slurred normal BP
Brand Name: Prinivil Antihypertensive closely for angioedema speech, restlessness Assessment for possible side effects:
Dosage: 5Mg Action: Pt complained of some dizziness, and a
Frequency: once a day Lowers BP by minor HA
Route: PO specific inhibition of
the ACE

Generic Name: Classification: Monitor for S/S, monitor N, dry mouth, constipation, Effectiveness of med: Pt appeared
Cymbalta Psychotherapeutic BP insomnia, diarrhea more at ease with everything
Brand Name: agent, Assessment for possible side effects:
Duloxetine antidepressant, Just complained of a dry mouth so
Hydrochloride SNRI fluids where given to her
Dosage: 30mg Action: Causes
Frequency: once a day potentiation of
Route: PO serotonergic and
noradrenergic
activity in the CNS

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