CSU Stanislaus BSNClinical Plan of Care

CLINICAL CARE PLAN & CARE MAP

Patient Data

Student: Chelsea Ruthrauff Date of Care: 11/14/19_ Patient initials: _Admit date:__Floor/room _Allergies: NKDA Code Status: Full

Demographics Gender: Age: Height: Not recorded in chart Weight: 85kg Primary language: Spirituality: Unknown
Vital signs T: 37.4℃ HR: 22 RR: 22 BP: 129/74 O2sat: 99% Pain: 0 Pain scale type: CPOT
Admitting Dx MVA
PMHx DM. Family is unaware of any other PMHx.
PSHx None documented. Family is unaware if pt has PSHx.
Surgery Surgery this admission: exploratory laparotomy 11/13/19 -small bowel repair, large bowel perforation, omentectomy, repair of mesenteric arterial
bleeding, small bowel anastamony, and appendectomy POD: one and two
Advance directive: None Isolation: Standard precautions VS Frequency: Q1hr
Diet order: NPO, TPN Activity order: Bedrest Vascular access: IVF: Fentanyl, Phenylephrine,
Norepinephrine, Propofol, and
Vasopressin
Oxygen therapy: Ventilated Foley: Indwelling foley catheter Feeding tube: OG tube Glucose checks: Q6H
PEEP: FiO2:
VTE prophylaxis: SCDs Drains/tubes: Peripheral IV, left AC Wounds/dressings: abdominal Telemetry: ECG
16g. Central IV, right triple lumen. incision, JP drain
Restraints: None Safety issues: Morse: 50 , risk for Braden: 12 D/C plan: Titrate pressors until
falls completely off. Titrate Propofol and see
how pt tolerates. Once stable, surgery
required for C2 fracture.

Pathophysiology: ​required – evidence based reference(s) and citation(s).

The MVA resulted in significant injuries to the pt including right clavicular fx, bowel perforation, mesenteric arterial bleeding, C2 fracture, and
hematoma between C2 and C4. The abdominal injuries are corrected and the C2 fracture has been stabilized but will require surgery. However, these
injuries may cause significant physiological changes. One significant concern is the C2 fracture. This can potentially cause paralysis of the arms and/or the
legs. Inflammation at the site could also restrict blood flow to the brain. Paralysis occurs depending on the severity and location of the fracture. Currently,
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CSU Stanislaus BSNClinical Plan of Care

the pt moves her legs in response to pain, but does not move arms. This indicates damage to the posterior portion of the vertebrae. It is likely that the pt is
showing signs of central cord syndrome which includes weakness or lack of movement of the arms and hands. It is important for the nurse to maintain
strict c-spine precautions to prevent additional damage to the vertebrae. The neurologist has ordered the MAP to be at 85 or greater, which is higher than
typically recommended. The higher pressure will ensure that blood is able to push past the inflamed areas in the neck to continue to oxygenate the brain.
Currently the pt is on three vasopressors to manage blood pressure and keep the MAP at 85 or greater. The nurse should also assess peripheral pulses
Q4hrs to look for possible changes in circulation related to the neck injury. An additional significant concern is the risk for sepsis. The bowel perforation
places the pt at significant risk for septic shock. Sepsis occurs as a result of bacteria entering the bloodstream. The bowel perforation is a prime
opportunity for this to occur. Shock occurs when the pt has adequate fluid volume, but is severely hypotensive. Poor perfusion means that oxygen is not
available to use glycolysis to produce energy. To compensate, the body uses anaerobic respiration which releases lactic acid. The pt had severely elevated
lactate levels which is another indication of possible septic shock. To manage this issue, the nurse must first treat the infection. The pt has an order for
a Zosyn drip, which is a broad spectrum antibiotic. Next, it is essential to manage the blood pressure to increase perfusion. This is managed by fluids,
vasopressors, and corticosteroids. The lactic acid levels may cause the pt to become acidotic. In this case, the pt was treated with albumin and sodium
bicarbonate. Once the pt is stabilized and the infection is treated, vasopressors are slowly titrated off and the pt can undergo surgery to repair the C2
fracture.

Lab and Diagnostic Test Data

LABS Normal RESULT RESULT 2 RESULT Reason for abnormal lab values related to patient care & nursing implications
Range 1 3
11/4, 0135
(Fill in Hospital 11/13, 1123 11/15, 0240
Norms)

CBC

● WBC 4-11 3.6 19.8 9.3 On the first day of admission, the pt had a decreased WBC count. On the second day,
this level rose and then stabilized on the final day of care. It is likely that this is r/t the
pt’s trauma and inflammatory response. Inflammation of the injured areas causes
WBCs to be elevated. The nurse should continue to monitor this value as the pt is
taking Zosyn as a prophylactic for infection. This medication may cause leukopenia
and neutropenia. The pt is at risk for developing sepsis so the nurse should assess for
signs and symptoms of infection and monitor for increased WBC levels.

● RBC 3.8-5.2 4.08 4.27 3.28 It is likely that RBCs, Hgb, and Hct are decreased as a result of blood loss. RBCs
carry Hgb and Hct is the ratio of RBCs in the blood. Typically, all of these labs are

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Hemoglobin 13-17.5 12.2 12.7 9.8 directly related to each other. Initially the values were not significantly low. They have
(Hgb) all become much lower by day three of admission. This may be a side effect of Zosyn.
The medication commonly causes a decrease in Hgb and Hct. It is important to assess
Hematocrit 35-47 36.4 38.4 28.9 the pt for signs of anemia and continue to monitor lab values. The nurse may consider
(Hct) speaking to the physician about switching antibiotics. If values become too low, the pt
may require a blood transfusion.

● MCV 80-98 89.4 90.1 85.9 This lab value is WNL.

● MCH 27-32 29.9 29.8 30.1 This lab value is WNL.

● MCHC 32-36 33.5 33.0 35.0 This lab value is WNL.

● RDW 11.5-14.5 14.5 15.4 15.1 The RDW is slightly elevated. This is a measure of the different sizes of RBCs. There
are many factors that may influence this lab including nutrient deficiency, anemia, and
trauma. It is most likely that this value is elevated due to trauma caused by the MVA.
It can also be influenced by the low Hgb, Hct, and RBCs. This number is not currently
concerning, but the nurse should still continue to assess this value. If it gets higher, we
should consider looking at another causes such as nutrient deficiency.

PLT COUNT 130-400 174 168 76 Decreased platelets may be caused by a variety of factors. It is either caused by the
body’s lack of producing platelets or an increase in platelet destruction. In this case, it
is likely that the body is not producing as many platelets as a result of infection. The pt
is also taking Zosyn which can cause thrombocytopenia. This value can be a concern
because it places the pt at a higher risk for bleeding. Corticosteroids can help to
correct this problem. The nurse should administer hydrocortisone as ordered and
consider requesting that the physician change the antibiotic. The nurse should also
continue to monitor this lab value.

WBC DIFF

NEUTROPHIL 34.0-74.0 86.4 84.2 Neutrophil count was elevated, which may be indicative of infection. It is likely to be
% caused by an inflammatory response in this pt due to trauma. The pt is at high risk for
infection r/t bowel perforation. The nurse should monitor for signs and symptoms of
infection, sepsis criteria, and continue to administer antibiotics as ordered.

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BANDS %

LYMPHOCYT 20.0-50.0 6.1 7.1 This lab value is very low. While autoimmune disorders may cause lymphocytopenia,
E% it is most likely that this is r/t infection or poor nutrition. The pt has been NPO for
three days and has not received any nutrition. The pt also has a high risk for infection.
The nurse should monitor for signs and symptoms of infection and/or sepsis,
administer antibiotics, and request an order for TPN.

MONOCYTE 2.0-14.0 7.4 8.6 This lab value is WNL.

%

CHEMISTRY 11/13,
0740

Sodium 136-145 149 144 143 This lab value is WNL.

Potassium 3.5-5.1 2.9 4.5 3.2 The pt is experiencing metabolic acidosis and is being given vasopressin. This would
normally make the nurse anticipate hyperkalemia. However, the pt has labs indicative
of hypokalemia. The pt is not taking diuretics but does have frequent urination
(-556.96) which may contribute to a loss of potassium. These low levels require the
nurse to intervene by administering potassium as ordered. The nurse should also
assess for signs and symptoms of hypo/hyperkalemia.

Chloride 98-107 120 116 111 The pt has somewhat elevated chloride which is often a symptom of dehydration.
However, sodium levels are WNL and the pt is receiving continuous fluids and has
good skin turgor, so it is unlikely that the pt is dehydrated. In this case, the pt has
metabolic acidosis which can cause increasing levels of chloride in the blood as
bicarbonate decreases. The nurse should monitor this level and administer sodium
bicarbonate based on bicarbonate labs and ABGs.

CO​2​(bicarb) 22-29 15 8 16 Low bicarbonate levels are very common in metabolic acidosis. The injuries caused by
the MVA are contributing to the production of lactic acid and contributing to
metabolic acidosis. In order to combat this problem, the nurse should administer
sodium bicarbonate push. If the labs are not corrected, the nurse should consider
requesting an order for a sodium bicarbonate drip.

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CSU Stanislaus BSNClinical Plan of Care

BUN 8-23 11 9 113 This lab value is WNL.

Creatinine 0.7-1.2 0.9 1.1 1.0 This lab value is WNL.

GFR >60 77.60 69.00 57.15 This lab value is WNL.

Glucose 70-110 154 230 222 The pt has been diagnosed with DM and uses Metformin at home to manage her
diabetes. The pt currently has an order for Lispro on a sliding scale. High glucose
levels are affected by diabetes, but are also elevated as a result of physiological stress
on the body. It is important for the nurse to check blood glucose Q6hr and administer
insulin as ordered to manage diabetes and improve wound healing. The nurse should
also monitor for signs and symptoms of hypo/hyperglycemia.

Calcium 8.8-10.2 6.9 8.7 9.2 Calcium levels were only somewhat decreased but then went back to WNL. It is
common to have decreased calcium levels in female pts older than 50. This could be
r/t diet, kidney function, or parathyroid function. Currently, the lab is WNL and
requires no intervention. The nurse should continue to monitor this lab and assess for
signs and symptoms of hypocalcemia.

Iron

Transferrin

Iron/
Transferrin

Phosphorus

Magnesium 1.6-2.6 2.0 2.2 1.9 This lab value is WNL.

Lactic Acid 0.5-2.2 6.3 8.1 4.0 Lactic acid levels were severely elevated in this pt. At one point, her lactic acid levels
were 10.1. This is caused by anaerobic respiration occuring because the cells in the
body did not have enough oxygen available for aerobic respiration. It is important for
the nurse to ensure adequate oxygen perfusion and administer sodium bicarbonate to
correct metabolic acidosis. The nurse should continue to monitor these levels Q6hr
and administer fluids as ordered. It is a positive sign that this lab value is steadily
decreasing.

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Serum Ketones

HbA1C

LIVER PANEL

Total protein 6.4-8.3 3.8 5.7 5.5 Total protein was initially very low but has since risen to just below normal limits.
Low protein may indicate damage to liver or kidneys. Kidney function appears
adequate based on lab values and urine output. There was likely some damage to the
kidneys during the initial trauma. This may be a result of the mesenteric artery bleed
as the organs may not have received adequate oxygenation. The levels are rising,
which is a good sign, but the nurse should continue to monitor this lab.

Albumin 3.5-5.2 2.0 3.0 2.9 Albumin levels were significantly low requiring the administration of albumin prior to
the day of care. When protein levels are low, albumin levels are typically decreased as
well. Low albumin is common in shock and inflammation which is the likely cause for
this pt. The nurse should treat other symptoms of shock and inform the doctor of the
albumin levels. The pt may require more albumin to be administered.

Bilirubin Total 0.0-1.2 0.3 0.7 1.4 This lab value is WNL.

Alk 40-129 53 64 45 This lab value is WNL.

phosphatase

HDL

LDL

AST 0-40 33 38 35 This lab value is WNL.

ALT 0-41 18 23 20 This lab value is WNL.

Lipase

Amylase

Ammonia

Cholesterol

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Triglycerides

Lactate

Serum Ketones

CARDIAC
PANEL

CPK

CPK-MB

Troponin

Myoglobin

BNP

COAGULATT 11/14, 0450 11/15,

ION 0620

PT 9.5-11.5 10.9 12.4 13.8 An elevated prothrombin time means that it takes the pt longer for blood to clot. This
pt also has low platelet levels which is causing the increased PT time. It is important
for the nurse to monitor PT, PTT, INR, and platelet levels to look for changes. It is
also important to assess the pt for signs of bleeding as her blood is not clotting
properly.

INR ratio <4.0 1.0 1.2 1.3 This lab value is WNL.

PTT 25-35 29 lab unable 37 This lab value is WNL.

to determine
value

Fibrin level

Fibrinogen 200-400 268 419 619 Fibrinogen is a factor in forming a blood clot. Levels often become elevated after a pt
has experienced bleeding and trauma such as in this instance. Fibrinogen should be
broken down into fibrin. Excess levels means that it is not being turned into fibrin the

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CSU Stanislaus BSNClinical Plan of Care

way that it should be, placing the pt at a higher risk for bleeding. The nurse must
carefully monitor all labs for clotting factors and assess the pt for signs of bleeding. If
levels continue to rise, the nurse should alert the physician.

Anti Factor Xa

Bleeding time

D-Dimer

Drug levels

UA​collection
type

Urine color

Urine
appearance

Specific gravity

Urine Ph

Urine glucose

Urine bilirubin

Urine blood

Urine Ketones

Urine Nitrites

Urine Protein

Urine
Leukocytes

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URINE
MICRO

WBC HPF

RBC HPF

Nitrate HPF

Epithelial

Bacteria

Mucous

CULTURES

URINE
CULTURE

Urine Tox
screen

CSF

● WBC

● RBC

● Glucose

● Protein

● Culture

Blood Cultures

Stool Cultures

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Sputum
Cultures

Nasal Cultures

11/13, 11/14, 0431

1123

ABG(FIO​2​ + 21-100 60 40 40 This lab value is WNL.

device)

pH 7.35-7.45 7.22 7.15 7.51 pH was initially decreased indicating acidosis but then became elevated which is a
sign of alkalosis. The acidosis is metabolic and likely caused by the trauma from the
MVA. The trauma and bleeding created an anerobic environment which made the cells
produce high levels of lactic acid. This was corrected by fluids, oxygen, and the
administration of sodium bicarbonate. The corrections may have caused the pt to
become somewhat alkaline. The nurse should continue to monitor these levels in
addition to bicarbonate and lactic acid.

PO2 75-100 149 74 92 When the pt was severely acidotic, the oxygen levels were extremely elevated. This is
an attempt to compensate for the acidosis. In this case, it is important for the nurse to
try and correct the cause of metabolic acidosis and administer sodium bicarbonate.

PCO2 35-45 27.2 31 22.5 Low pCO2 levels are also an aspect of acidosis. In this case, the pt is attempting to
compensate by expelling excess CO2. Again, it is important for the nurse to monitor
this lab value and treat the cause of the metabolic acidosis.

Bicarbonate 22-26 10.8 10.1 17.6 Low bicarbonate is a key factor in metabolic acidosis. The less bicarbonate, the more
acidotic the pt will become. The nurse should administer sodium bicarbonate bolus
and then consider requesting an order for a sodium bicarbonate drip. The nurse should
assess for physical manifestations of metabolic acidosis and continue to monitor lab
values.

Oxygen 95-100 98.5 90.7 97.8 This lab value is WNL.

Saturation

Anion gap

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Tox Screen

Therapeutic
Drug Levels

D​IAGNOSTIC
T​ESTS

( A​LL
DIAGNOSTIC
​HOULD​ B​E
TESTS​ S
HERE​)

EEG

X ray Chest: 11/12/19, 2349

Impression:
1. Pneumoperitoneum, concerning for bowel perforation.
2. Nondisplaced fx of the right clavicle.
Chest: 11/13/19, 0848 to confirm central line placement
Impression: There is a bibasilar airspace disease that could represent atelectasis, aspiration, or pneumonia.
Angiography

Heart Cath.
Lab
CT Scans Abdomen and Chest: 11/12/19 2348
Impression:
1. Soft tissue thickening with increased density anterior to the tracheostomy tube, concerning for hematoma. Otherwise no acute traumatic
injury within the chest.
2. Nondisplaced right clavicular fx
3. Large pneumoperitoneum consistent with bowel perforation. The site of the perforation is probably in the hepatic flexure.
4. Findings are suggestive of mesenteric injury with moderate amount of hemorrhage.
5. Finds are concerning for small bowel wall thickening/contusion in the right lower quadrant.

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CSU Stanislaus BSNClinical Plan of Care

6. Soft tissue contusion in the lower anterior abdominal wall and the right upper chest wall.
Head: 11/12/19, 2348
Impression: No acute intracranial abnormality identified on this noncontrast CT of the brain.
Maxillofacial w/o contrast: 11/12/19, 2348
Impression:
1. Prevertebral large hematoma causing midline structure deviation, including the trachea, esophagus, vocal apparatus
2. Maxillofacial technique reveals no acute fractures. Complete debris-hematoma fills nasopharynx and nasal passages.
3. Hangman’s fracture odontoid pars interarticularis bilateral. Odontoid malalignment. See dedicated CT exam.
Cervical w/o contrast: 11/12/19, 2348
Impression:
1. C2 hangman’s fracture. Odontoid anterior malalignment. Cervical ligament trauma.
2. C2-C4: severe central stenosis and cord compression. Cervical epidural hematoma.
3. Current findings discussed with neurosurgery PA
Lumbar and thoraxic w/o contrast: 11/12/19, 2348
Impression: No acute compression fx or subluxation in the thoracic and lumbar spine.

MRI

Endoscopy

Nuclear Scan

Medications
Generic Dose/Route Action of Drug Possible Nursing Considerations related to patient care and teaching
Trade Name Frequency Purpose Side Effects (What to assess, when to hold, what to teach, etc. Anything
Drug classification Rate of (​
specific to Pt​) other than the side effects that the hospitalized patient
(​Therapeutic & Administration needs to know.)
Pharmacologic)​ (if needed)

G: Fentanyl 1000mcg in 100mL Purpose: This medication is Possible side Start at 50mcg/hr and monitor RASS and CPOT
T: Sublimaze IV continuous given to control pain in the pt effects include: score. Pain: 1-3: increase by 12.5mcg/hr Q5min
Th: Opioid analgesics infusion as she is intubated, post-op No primary side Pain: 4-6: increase by 25mcg/hr Q5min
Ph: Opioid agonists effects, but could Pain: 7-8: increase by 50mcg/hr Q5min

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CSU Stanislaus BSNClinical Plan of Care
Start at 50mcg/hr. from a laparotomy, and
Max infusion rate: recovering from an MVA.
200mcg/hr.
Action: Fentanyl binds to
opiate receptors in order to
alter the pt’s perception of
pain.
G: Hydrocortisone 50mg in 1mL IV Purpose: In this pt,
T: A-Hydrocort, Cortef, push Q8H hydrocortisone is a steroid
Cortenema used to maintain blood
Th: Antiasthmatics, pressure in the event of septic
corticosteroids shock.
Ph: Corticosteroids
Action: This medication
functions by suppressing the
normal immune response.
This medication also
introduces additional cortisol
and has mineralocorticoid
capabilities.
Revised: Medical Surgical Committee 5/17/19
result in apnea or Pain: 9-10: max rate 200mcg/hr
laryngospasm RASS: -3, -4, -5: stop infusion and notify physician
for oversedation.
Prior to administering this medication, the nurse
should assess respiratory rate and blood pressure
because Fentanyl has the potential to cause
respiratory depression. This medication should be
held if these values are below the normal range.
The pt’s pain level should also be monitored
before and after administering medication.
Because the pt is intubated, the nurse should use
the CPOT pain scale. This value should be
assessed before and after administration in order
to monitor the effectiveness of the medication. The
family should be educated on the purpose of this
medication and signs that the pt may be
experiencing pain.
Possible side Prior to administering this medication, the nurse
effects include: should assess blood pressure and I/Os. During
Depression, septic shock, steroids can be used to maintain BP
euphoria, in addition to vasopressor therapy. IV push should
hypertension, be given over 30 seconds per 100mg. This
anorexia, nausea, medication has a great deal of side effects, so
acne, decreased during therapy, the nurse should frequently assess
wound healing, for negative reactions. Intake and output should
ecchymoses, be regularly monitored in addition to lab values.
fragility, Some significant labs include electrolytes and
hirsutism, glucose. This medication may cause
petechiae, hyperglycemia. It can also reduce WBCs,
adrenal potassium, and calcium and increase sodium.
suppression, Long-term treatment may cause suppression of
muscle wasting, the adrenal gland, so the nurse should assess for
osteoporosis, changes and inform the physician. The family
cushingoid should be educated on potential side effects and
appearance purpose of medication. Medication should be
tapered down and not stopped suddenly. Suddenly
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CSU Stanislaus BSNClinical Plan of Care
G: Insulin Lispro
T: HumaLOG
Th: Antidiabetics,
hormones
Ph: Pancreatics
G: Magnesium Sulfate
T: Magnesium Sulfate
Th: Mineral and electrolyte
replacements/supplements
Ph: Minerals/electrolytes
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Sliding scale Purpose: This medication is
Subq injection used for daily control of
Q6H hyperglycemia in the pt. It is
given prn based on current
blood glucose levels.
Action: This medication is a
rapid acting insulin which
reduces blood glucose by
increasing the uptake of
glucose in the muscles and
fat. This medication should
be used with a long-acting
insulin.
1g in 100mL IV Purpose: Indication: For
piggyback prn hypomagnesia
rate: 100ml/hr
Action: These medication
replaces magnesium in the
event of deficiency.
stopping medication may cause adrenal
insufficiency.
Possible side Prior to administering medication, the nurse
effects include: should check the blood glucose levels. If the pt is
Hypoglycemia, hypoglycemic, the insulin should not be
hypokalemia administered. The nurse should compare the
blood glucose to the sliding scale to determine the
appropriate amount of insulin to administer. This
form of insulin is rapid acting and can be given
Q6H. The blood glucose should be checked Q6H.
The family should be taught about signs and
symptoms of hypo/hyperglycemia, how to
administer medication, and how to perform a
blood glucose check. This medication may be
mixed with other forms of insulin. It is a high alert
medication requiring two RN signatures.
Possible side Magnesium: 1.4-1.8-give 1g over one hour.
effects include: Recheck after infusion is complete
Diarrhea Magnesium 1.3 or less-give 1g over one hour x two
doses. Recheck after infusion is complete.
Prior to administering this medication,
magnesium levels should be checked and dosaged
should be matched with the above order. If lab
values are not abnormal, then the medication
should be held. The nurse should also assess for
physical manifestations of hypomagnesemia
before and after administration and signs of
hypermagnesemia after administration. The nurse
should also regularly assess vital signs and ECG
during therapy. If respirations are below 16, the
medication should be held. The family should be
educated on the purpose of administering
magnesium sulfate as well as possible side effects.
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G: Norepinephrine 16mg in D5W Purpose: Indication: for
T: Levophed 234mL IV prn hypotension. Start if MAP
Th: Vasopressors less than 85mmHg.
Ph: N/A
Action: Norepinephrine
functions by stimulating
alpha-adrenergic receptors.
This stimulation causes
contraction of the blood
vessels which increases blood
pressure.
G: Pantoprazole 40mg IV push Purpose: This medication is
T: Protonix daily used to prevent stomach
Th: Antiulcer agents ulcers caused by stress.
Ph: Proton-pump inhibitors
Action: Pantoprazole
functions by binding to a
specific enzyme in order to
reduce the amount of acidic
gastric secretions. This allows
for healing of erosive
esophagitis and acts as a
prophylactic for stomach
ulcers.
G: Phenylephrine 60mcg/min Purpose: To maintain MAP
T: Vazculep continuous IV to >85. Treatment of
Th: Vasopressors maintain MAP of hypotension. This medication
85
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Possible side Start at 2mcg/min. Titrate by 1mcg/min every 5
effects include: minutes. Goal: MAP between 65-85.
No common side Max: 20mcg/min. For MAP <50mmHg, increase
effects. to max rate and notify physician. For MAP
Additional effects <65mmHg and max rate reached, notify physician.
may be dizziness, A central line is required for this dosage.
headache,
restlessness, Prior to administering this medication, the nurse
dyspnea, should assess the pt’s BP and MAP. If the MAP is
hypertension greater than 65mmHg, the medication should be
held. During administration, the BP should be
checked Q2-3min and the medication should be
titrated as ordered. ECG should also be utilized to
monitor heart rhythms during therapy. The
family should be taught about the purpose and
side effects of norepinephrine. If the pt was alert,
he should be taught to inform the nurse if he
experiences a headache, chest pain, or dyspnea.
Possible side Prior to administering this medication, the nurse
effects include: should assess the pt for abdominal pain, quality of
No common side stool, and AST, ALT, and bilirubin levels. This
effects. medication can reduce liver function.
Additional effects Pantoprazole may also cause hypomagnesemia.
may be Medication should be held in the event of signs of
abdominal pain, liver failure. During therapy, the nurse should
diarrhea, assess for signs of liver failure and
flatulence hypomagnesemia. It is important for the nurse to
frequently assess lab values. The nurse should
educate the family on purpose and side effects of
medication. This medicine should not be taken
with alcohol, NSAIDS, or GI irritating foods. This
medication should be pushed over two minutes.
Possible side Prior to administering this medication the nurse
effects include: should assess the pt’s BP and MAP. For a MAP
No common lower than 85, the nurse should consider
adverse reactions, increasing the dose. For a MAP greater than 85,
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CSU Stanislaus BSNClinical Plan of Care
Ph:Adrenergics, alpha
adrenergic agonists,
vasopressors
G:
Pipperacillin-tazobactam
T: Zosyn
Th: Anti-infectives
Ph: Extended spectrum
penicillins.
G: Potassium chloride
T: Klor-Con
Th: Mineral and electrolyte
replacements/supplements
Ph: N/A
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works with norepinephrine
Titrate down per and vasopressin.
order
Action: Stimulates
alpha-adrenergic receptors,
which causes the blood
vessels to constrict.
3.375g in 15mL IV Purpose: Indicated for bowel
piggyback Q8H perforation that could lead to
infection. This is given to
Infuse over 4hr. prevent infection and sepsis.
Action: This medication
binds to the cell wall of the
bacteria which eventually
causes the death of the
bacteria. This is a broad
spectrum antibiotic.
10mEq in 100mL Purpose: Indicated for
IV piggyback PRN hypokalemia.
20mEq in 100mL Action: This medication
IV piggyback PRN functions by replacing
with central line potassium in the event of
hypokalemia.
but could cause the nurse should consider lowering the dose.
headache, Between the three pressors, this medication should
blurred vision, be the first to be completely titrated down. This
hypertension, and medication requires continuous ECG monitoring
arrhythmias. and BP monitoring Q2-3 minutes until stabilized.
The family should be educated on the purpose of
the medication and the goal to eventually titrate
down and stop medication.
Possible side Prior to administering this medication, the nurse
effects include: should assess renal function and any allergy to
diarrhea, rashes, penicillins. Medication should be held for
pain/phlebitis at penicillin allergy and given cautiously in impaired
IV site renal function. The nurse should also assess for
signs and symptoms of infection such as fever,
WBC elevation, and tachycardia. Bowel function
and skin should also be assessed during therapy to
look for adverse reactions. It is important to
monitor labs including CBC, potassium,
coagulation studies, AST, ALT, and BUN. The
medication may cause an increase in BUN, AST,
ALT, PTT, PT, and creatinine. It may also cause
leukopenia, neutropenia, thrombocytopenia, and
decreased hemoglobin and hematocrit. Educate
family on the purpose of this medication and the
risk for superinfection in response to the
medication.
Possible side Potassium: 3.8-3.9-give 10mEq over 1hr x2 doses
effects include: Potassium: 3.5-3.7-give 10mEq over 1 hr x3 doses
abdominal pain, Potassium: 3.0-3.4-give 10mEq over 1hr x4 doses
diarrhea, Potassium: 2.9 or less-give 10mEq over 1hr x5
flatulence, doses and notify physician.
nausea, and Recheck potassium after infusion is complete
vomiting.
Prior to administering this medication, the nurse
should check potassium levels. If the pt is
hypokalemic, the nurse should refer to the above
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CSU Stanislaus BSNClinical Plan of Care

dosing. If the potassium levels are WNL, the

medication should be held. The nurse should
assess for signs and symptoms of hypokalemia
before and after administration and symptoms of
hyperkalemia after administration of the
medication. Lab values should be rechecked after
the potassium has been completely administered.
During therapy, the nurse should frequently
monitor vitals and ECG. Magnesium levels should
also be assessed. If the pt experiences toxicity,
symptoms may include slow, irregular heartbeat,
weakness, confusion, dyspnea, and arrhythmias.
the nurse should stop the potassium infusion and
administer sodium bicarbonate. The family should
be educated on the purpose of the medication and
signs and symptoms of hyp/hyperkalemia.
G: Propofol Continuous IV Purpose: Propofol is used to Possible side Start at 10mcg/kg/min. Increase by 10mcg/kg/min
T: Diprivan Titrate for Goal sedate the pt during effects include: every 5min PRN until goal is reached. Max
Th: General Anesthetics RASS: -2 or BIS: intubation and while Bradycardia, infusion rate: 50mcg/kg/min. Notify physician for
Ph: N/A 40-60 recovering from C2 fracture. hypotension, MAP <60mmHg or HR <50.
burning, pain,
Start at Action: This medication stinging Prior to and during administration of Propofol,
10mcg/kg/min causes sedation and may the nurse should continuously assess vital signs.
result in amnesia. The The nurse should maintain the pt’s airway and
mechanism of action is not ensure adequate breathing. During sedation, the
known. nurse should monitor RASS and BIS scores and
titrate the medication to keep the pt between the
ordered ranges. The nurse should educate the
family on the purpose of sedation and the risk for
respiratory effects. The dose should be decreased
for a MAP lower than 60mmHg.
The nurse should consider speaking to the
physician about titrating this medication down to
evaluate the pt’s response.

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CSU Stanislaus BSNClinical Plan of Care
G: Vasopressin 20 units in 100mL Purpose: Indications:
T: Vasostrict IV additive prn hypotension, MAP
Th: Hormones <85mmHg
Ph: Antidiuretic hormones, Rate: 12mL/hr
vasopressors Action: Vasopressin is a
synthetic form of antidiuretic
hormone. It functions by
changing the permeability of
the renal ducts which allows
greater absorption of water,
this increasing blood
pressure. It also functions as
a vasoconstrictor.
Revised: Medical Surgical Committee 5/17/19
Possible side Start if MAP less than 85mmHg to maintain a
effects: No goal of MAP 85mmHg. Maintain drip at 0.04
common adverse units/minute. Do not wean until all other
reactions, but vasopressors are off. When time to wean, wean by
may cause 0.01 units per minute every 30 minutes to
dizziness, angina, maintain MAP of 85mmHg.
and MI.
Prior to administering this medication, the pt’s BP
and MAP should be checked. The nurse should
follow the above criteria and administer
medication as ordered. This medication is
contraindicated in pt’s with chronic renal failure.
During therapy, the nurse should continuously
monitor BP, HR, and ECG. The nurse should also
assess for edema and monitor electrolytes. The
nurse should also listen to lungs for any retained
fluids and monitor I/Os. The family should be
taught about the purpose of this medication and
how it will eventually be stopped once the MAP is
in acceptable limits without the use of medication.
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CSU Stanislaus BSNClinical Plan of Care

Chief Medical Dx: Injuries from MVA including: C2 Fx, hematoma between C2-C4, small/large bowel perforation, right clavicular Fx
Priority Assessments: Head-to-toe, ECG, labs, vitals, neuro focused assessment

Nursing Interventions Classification (NIC)

ND Interventions Evaluation of response

1. Unstable blood glucose Head-to-toe looking for signs/symptoms Every 6 hours, the pt did have elevated blood glucose, but
level r/t physiological of hypo/hyperglycemia. responded well to the insulin. The history of the pt is mostly
stress and DM as Blood glucose test Q6hr. unknown, but it may be helpful to recommend that the
evidence by blood glucose Treat elevated levels with Lispro sliding physician add an order for a long-acting insulin such as Lantus.
levels of 154, 230, and scale. The pt did not show any signs of hypo or hyperglycemia.
222.

2. Impaired verbal Used Hmong translator to speak with Initially the family behaved as if the information was
communication r/t family. understood. However, a family friend showed up and explained
language barrier as Asked family members if they had that the family did not understand but was uncomfortable
evidence by family questions after explaining information. asking for clarification. We clarified questions by the family
sending a friend to Answered all questions by the family members and the family expressed understanding. The family
explain that they do not members. responded well to the use of a Hmong translator.
understand what is Used simple terms and avoided medical
happening to the pt. jargon.

3. Risk for impaired Strict c-spine and log roll. Pt maintained a MAP >85. Vasopressors were titrated down and
cerebral perfusion r/t MAP goal: >85 the pt tolerated well. Neuro checks showed no change in
spinal cord injury and Administer vasopressors as ordered. condition. Rass -4, GCS: 6. No further injury to neck occured.
hypotension. Frequent neuro checks Pt had adequate cerebral perfusion.

4. Administered Zosyn as ordered.
Risk for infection r/t Monitored vital signs.
bowel perforation, Monitored lab values (WBC, cultures,
intubation, and neutrophil %, monocyte %, leukocyte
indwelling foley catheter. %).
Head-to-toe assessment
Oral care Q4hr.
Pt remained tachycardic during both shifts but displayed no
other abnormal vital signs. WBCs stabilized and were WNL but
neutrophil % was elevated. Breath sounds were coarse, but no
other signs of ARDS or septic shock. Pt tolerated medications
well and did not show any other indications of infection.

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CSU Stanislaus BSNClinical Plan of Care

Foley care BID.

Nasal care BID.
Frequent suction.
NPO to prevent aspiration.
Glucose checks Q6hr
Administered glucose as ordered.
5. Perform interventions above to prevent The pt tolerated antibiotics well. She was tachycardic and had
Risk for shock r/t sepsis infection. an elevated neutrophil %, but showed no other signs of
and metabolic acidosis. Administer Zosyn as ordered. infection. Blood pressure was maintained through the use of
Administer continuous fluids as vasopressors and fluids and was consistent with a MAP >85.
ordered. Sodium bicarbonate levels stabilized and ABGs were WNL.
Assess vitals Q1hr Lactate decrease from 10 at the highest down to 4.
Administered vasopressors as ordered.
Head-to-toe.
Administer sodium bicarbonate.
Monitor lab values.
6. Risk for aspiration r/t Place pt in reverse trendelenburg. Frequent gurgling sound coming from pt’s mouth which was
RASS: -4, GSC: 6, and Frequent suction. relieved by suction. Pt tolerated suction and oral care well. The
intubation. NPO. pt was free from aspiration during the days of care.
Oral care Q4hr.

Assessment
H​EAD​ / N​
EURO

L.O.C. RASS: -3, GCS: 6. Gag reflex present. Weak, induced cough. Pt withdraws from pain but does not respond to voice of
follow commands.
Optical PERRLA. Pupils are sluggish. R: 2.4, L: 2.3. Some periorbital edema.
Head and neck Cervical collar for C2 fracture. CT showed C2-C4 hematoma. No injury to the head. Some facial edema.
Nose and Throat Dark red bleeding from the nose: requires suction. Nares patent and moist. Pt is ventilated. Mouth is pink and moist. Some
bleeding in the mouth. Oral care Q4hr.

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 CSU Stanislaus BSNClinical Plan of Care

Gross and Fine Motor Withdraws from pain. Does not follow commands. Limited, passive ROM in all extremities.

R​ESPIRATORY

Pulmonary RR: 22. Ventilated: PEEP: 5, FiO2: 25%. Tube is 22 at the lip. Lower lobes are diminished. All lobes are coarse. Chest
expansion is equal, consistent with ventilator. No use of accessory muscles.
Breast and back No ecchymosis, skin is intact.

C​ARDIO​-V​ASCULAR
Cardiac HR: 114, BP: 129/74. S1/S2 sounds audible. Regular rate and rhythm. Frequent sinus tach.

Central Chest and abdomen are warm, pink, and dry. No evidence of impaired perfusion.
Peripheral Bilateral peripheral pulses +1. Bilateral pedal pulses +1. Nail beds are pale. Cap refill 3-5 sec. Extremities are cool to the
touch.

G​ASTROINTESTINAL

Abdominal OG tube 45 at the lip. Absent bowel sounds. Non-distended, soft upon palpation. Midline incision from exploratory
laparotomy. No redness or discharge. JP drain on right side with serosanguinous drainage.
Nutritional NPO, TPN.

G​ENITOURINARY

Pelvic and rectal Indwelling urinary catheter. -556.96 Skin intact, no ecchymosis. Foley/peri care performed BID. Last BM prior to hospital
admission.

M​USCULOSKELETAL Unable to follow commands. Withdraws from pain. LLE/RLE: 1/5 LUE/RUE: 0/5

I​NTEGUMENTARY

Skin / Hair Hair clean and well-kept. Skin is warm, pink, and dry. Edema in all extremities. Bilateral ecchymosis of calves. Edema and
ecchymosis of the right shoulder consistent with midclavicular fracture. Right femoral line (triple lumen), left arterial line,
and left AC peripheral line (16g). All lines are patent and free from infiltration.

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CSU Stanislaus BSNClinical Plan of Care

SBAR REPORT: ​(What did you report off to the RN upon end of shift)
S: ​The pt is a 57 year old female who presented to the ER after an MVA early in the morning of 11/13/19.
B:​ The pt was restrained in the backseat of the car with her husband who is a pt at another hospital. The car was hit head on and the
pt had a GCS of 6 on the scene. She was intubated in the ER, but was a difficult intubation. The pt was then sent to the OR for an
exploratory laparotomy. During the procedure, the surgeon performed a small bowel repair, an omentectomy, an appendectomy, a
small bowel anastomosis, repair of a large bowel perforation, and repair of mesenteric arterial bleeding. She also has a right clavicular
fracture, C2 fracture (strict C-spine and log roll), and a hematoma between C2-C4. New dx of compression cord syndrome. The pt is
visiting her family from Laos and only speaks Hmong. Most of the family has limited English, but is constantly present and very
concerned about care. The family is unsure of the pt’s medical history.

A:
A. Airway: ​The pt is intubated (22 at the lip) and using a ventilator. PEEP: 5, FiO2: 25%. Tolerating well. Moderate
blood tinged secretions removed from ETT.
B. Breathing: ​RR: 22. Breath sounds are coarse and diminished in all four lobes. Chest expansion is symmetrical,
which is consistent with ventilator. No use of accessory muscles.
C. Circulation: ​HR: 114, BP: 129/74. Pt has been sinus tachycardic during all of care. S1/S2 sounds are audible.
Regular rate and rhythm. Goal MAP: 85. Was on Phenylephrine, Vasopressin, and Norepinephrine. Phenylephrine has been
discontinued. Norepinephrine has been titrated down to the lowest dose. Peripheral pulses +1 bilaterally. Pedal pulses +1
bilaterally. Hands and feet warm to the touch. Nail beds are pain and cap refill 3-5 seconds.

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CSU Stanislaus BSNClinical Plan of Care

D. Neuro: ​ RASS: -3, GCS: 6. Weak, induced cough. Gag reflex present. Withdraws from pain-movement of legs, but
no movement of the arms. Does not follow commands. PERRLA. Pupils are sluggish, but equal. CT shows no head injury.
Receiving Propofol at minimum dose (10mcg/kg/min).
E.Exposure/ Skin: ​Skin is warm, pink, and dry. Ecchymosis and edema of the right shoulder, consistent with
clavicular fx. Ecchymosis of the calves-more defined on right leg. Midline incision of the abdomen. Edges are approximated
with minimal drainage and no redness or inflammation. JP drain with serosanguinous drainage. Pt has an indwelling foley
catheter. I/O -556.69. Triple lumen central line in the right femoral artery. Left AC peripheral IV (16g). Lines are patent with
no sign of infiltration. Arterial line in the left hand. Still functioning for pressures and flushes well, but unable to draw blood.

No BM since admission. Bowel sounds are absent. Currently NPO, but considering TPN. OG tube 45 at the lip. Pain: 0 using
CPOT scale.
R: ​Continue frequent assessment, I/O Q1hr, glucose checks Q6hr, foley care, oral care, and titrate pressors down maintaining a
MAP of 85. Use strict c-spine and log roll. Reposition Q2hr. Continue to answer questions from the family member and utilize
adequate translation.

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CSU Stanislaus BSNClinical Plan of Care

ECG​ Documentation-​ Used only 5​th​ semester

Rhythm:​Atrial rhythm: Regular _______________ Irregular _________________ Ventricular rhythm: Regular _______________ Irregular
__________________

Rhythm:​Atrial rhythm: Regular ___________ Irregular _________ Ventricular rhythm: Regular ____________ Irregular __________________

Rate:​Atrial Rate ​116​___ Ventricular rate ​116​_ PR interval ​ 0.17​____QRS interval ​0.11​______QT interval ​0.36​____

Conduction:​Is AV conduction normal? (Y/N)_​Y​________ If not, why is it abnormal? ​N/A​______________________________

P wave normal? (Y/N) _​Y​____QRS complex normal? (Y/N) _​Y​______ Are all of the QRS complexes the same? (Y/N) _​Y​_____________

Are there premature beats? (Y/N) __​N​_Atrial _​N​__ventricular ​N​__Interpretation of rhythm: ​The pt is experiencing sinus tachycardia, but
otherwise has a regular rhythm.

Potential hemodynamic ​consequences ​of this rhythm and ​interventions​ for this rhythm: _​Sinus tachycardia may lead to ineffective perfusion of the
body. The rapid heart beat prevents the heart from fully filling with blood. Each time the heart pumps blood to the rest of the body, there is less
volume so the heart must pump faster to properly oxygenate the organs. The rate is only mildly elevated right now, which may be a result of the
pressors being used to increase the MAP. Pressors are currently being titrated down, so no further intervention is necessary.

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CSU Stanislaus BSNClinical Plan of Care

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CSU Stanislaus BSN Clinical Plan of Care

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CSU Stanislaus BSN
Course ​NURS4810​______ Instructor ​Josh Merriam​______
Please evaluate your performance during clinical today using the following concepts:
Areas of Strength Today (Date)_​10/3/19​___
Organized: I have become more organized
during the clinical day by creating a plan of
action based off of the orders for the pt. I create
the plan at the beginning of the shift and change
priorities with new orders throughout the day.
While I still have more to work on, it has
become an effective way to manage the tasks
required to care for my pt.
Well-prepared: I felt very prepared to care for
my pt. I studied all the information and looked
up the pathophysiology. We had also just
Revised: Medical Surgical Committee 5/17/19
27
Clinical Plan of Care
Student Clinical Self Appraisal
Instructions:
Areas Needing Growth-Include plan of
improvement
Self-initiated: While I have certainly
improved in initiation, I have a great deal to
work on. During my first clinical day this
week, I felt prepared to initiate care.
However, my nurse seemed less comfortable
allowing me to do everything and often
performed interventions before I could get to
them. We only had one pt and she was just
coming back after an extended time off so she
may have wanted to do more of the care
herself. I allowed her to instead of taking
CSU Stanislaus BSN
discussed septic shock in class, so I felt pretty
comfortable with the pt’s diagnosis.
Rapport: During this clinical, interactions with
the family were challenging due to language and
cultural barriers. I made sure to acknowledge the
daughter and make sure that she felt comfortable
and knowledgeable about her mother’s
condition. While there were still challenges, I
believe that I gained the daughters trust as she
responded very well to me and often went to me
with questions.
Client Advocate: The nurses and doctors
frequently commented on the pt being
unrestrained in the car. However, I found in the
initial physician document that he said that she
was unrestrained but in his assessment
mentioned that she had marks on her skin from
the seatbelt. Her injuries (chest, abdomen, and
right clavicle) were also consistent with seat belt
injuries. I also spoke to the family and found that
they also stated that she was restrained. It did not
actually matter to her care, but it bothered me
that the staff seemed to be somewhat
judgemental in the assumption that she was
unrestrained. I spoke up to my nurse about it and
he corrected the physician using all of my
evidence. I felt that it was important for the pt to
be represented well even if it did not affect her
medical outcome.
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28
Clinical Plan of Care
initiative myself. In the future, I will speak up
and offer to do more myself.
Knowledgeable: While I was aware of the
disease process, it would have been helpful to
have been more knowledgeable about Hmong
culture. I have had minimal experience with
Hmong pt’s and am unsure of some cultural
beliefs. In the future, I would like to do better
cultural research and if possible, ask the pt
and family about cultural beliefs.
Skills acquisition: I had the opportunity to
work on drawing blood from an arterial and
venous lines. While I thought I was
comfortable with the skill, I realized that I
was unaware of which color tubes were
required and the order of the draw. I also
failed to bring extra supplies with me and had
to leave the room to get more. I learned from
the experience and have learned about the
different tube colors and order of draw. I have
also learned to always have extra supplies
when performing an intervention.
Team player: While I am always willing to
help others, I would like to work on offering
the help more often. In future clinicals, I plan
to be intentional about looking for
opportunities to help other nurses.
CSU Stanislaus BSN Clinical Plan of Care

Instructor Comments:

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 CSU Stanislaus BSN Clinical Plan of Care

Student Clinical Self-Appraisal

EXAMPLE

Weekly (turn in with Care Plan/Map)

Student: ​Sally Jones​ Course: ​2910​ Instructor: J​ ohnson

Areas of Strength Today (Date) ​1/1/xxxx Areas Needing Growth-Include plan of

improvement

Client advocate: It is hard to speak up for a

Self-Initiated: New experiences intrigue me. When given the
chance to try something new, I jump on it. When doing my patient
assessment, I was very focused and went right to work
Leadership: When we had extra time, I got an instructional video on
diabetes and suggested to my patient we watch it.
Communication/rapport: Able to communicated effectively with my
Spanish speaking patient through the help of a nursing assessment
who spoke to language.
client when you are a student. Many
techniques are performed differently in a
hospital setting than in school. The best
approach is to question anything you feel
uncomfortable about.
Safety: I always try to be as safe as possible. I
need to remember to wash my hands more
often, be aware of surroundings (housekeeper
mopping), etc.

Well-prepared: All equipment here; paperwork on time

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 CSU Stanislaus BSN Clinical Plan of Care

Technical skills: Tried to start an IV. Need

more confidence in technical skills and more
Knowledgeable: Well-prepared on care of patient with CHF. Know
practice
what sounds should be heard in lung fields

Critical thinking: I should have been able to

figure out that oxygen is as an important drug
in CHF as Lasix. Now I know.

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