CLINICAL DOCUMENTATION PACKET

STUDENT’S NAME: Priyal Parikh DATE:

* Place an asterisk in front of all significant data throughout the tool that would indicate actual or potential problems.

CLIENT INITIALS: A.B. AGE: 37 SEX: ROOM NUMBER: 234

M

ADMISSION DIAGNOSIS / DATE: CURRENT DX: Chest Pain and Upper GI

Pain
SURGERIES / DATES: N/A
REASON FOR ADMISSION (Patient’s own words): chest pain and pain in my upper abdomen for 4 hours and it
wasn’t getting better
PAST MED/SURG HISTORY: Hypothyroidism, hypertension, glaucoma, diabetes type II
ALLERGIES: Acetaminophen HEALTH INSURANCE: Yes ☒ / No ☐ Horizon BCBS
ADVANCE DIRECTIVE: Yes ☒ / No ☐ Full Code PRESENT IN THE MED RECORD Yes ☒ / No ☐
   
RELIGIOUS PREFERENCES: Catholic
PRIMARY LANGUAGE: English Highest Level of Education: Associates degree in
Business Management
SMOKER: : Yes ☐ / No ☒ PPD: N/A Other Tobacco: Yes ☐ / No ☒ Type, Frequency, Amount: N/A
Quit in 2014, smoked 1
pack/day for 7 years
ALCOHOL: Yes ☒ / No ☐ Type, Freq & Amount: socially
PRESCRIPTION Drugs for Nonmedical Reasons: Yes ☐ / No ☒
Type, Amt. & Freq. N/A
ILLEGAL Drugs Yes ☐ / No ☒ Type & Frequency: N/A

NURSING ORDERS
Frequency: Every 4 hours,
VITAL SIGNS OXYGEN Room air
continuous tele monitoring

ACTIVITY As tolerated THERAPIES N/A

SAFETY
DIET Low sodium diet 1 person assist
PRECAUTIONS
I&O N/A WEIGHT (kg) 90.9 kg
IV FLUIDS
N/A TUBES N/A
(TYPE & RATE)
Finger Stick Frequency: Before meals and at
ISOLATION Type: N/A
Blood Glucose night

SCHEDULED SURGERY/PROCEDURES/TESTS/DATES: ECHO- 12/16/2020

ADDITIONAL INFORMATION: Additional Information

1
 Patient’s Vital Sign TRENDING for last 4 recent assessments

DATE
TIME 1100 Time 2nd VS Time 3rd VS Time 4th VS
Temp 98.2° Temp° Temp° Temp°
F☒ C☐ F☐ C☐ F☐ C☐ F☐ C☐
HR 80/min HR/min HR/min HR/min
BP 119/79 SBP/DBP SBP/DBP SBP/DBP
RR 18/min Resp/min Resp/min Resp/min
O2 Saturation 98% SpO2% SpO2% SpO2%
Pain Score 6/10 Pain/10 Pain/10 Pain/10

24 hour Intake/Output
TOTAL INTAKE: N/AmL TOTAL OUTPUT: N/AmL
Oral / TF IV Urine Emesis Tubes/Drains
Oral/TF N/A N/A N/A N/A

IV Access
#1 #2 #3 #4
Type S IV #2 Type IV #3 Type IV #4 Type
Size 18 G IV#2 Size G IV#3 Size G IV #4 Size G
Site Right AC IV #2 Site IV #3 Site IV #4 Site
Date inserted
Flush N/A IV #2 Flush IV #3 Flush IV #4 Flush

CVC = Central Venous Catheter, P= Peripheral, IP= Infusaport, IDC= Intradialytic Catheter PICC=
Peripheral Central Catheter, S = Saline Lock
Skin
COLOR: Normal TURGOR: Fair

Wounds/Incisions/Rashes (Identify each of the diagrams and number them.

Give a full description, measurements; drainage and wound care treatment of each area).
Include pressure ulcer stage (if present),

2
 1. N/A

2. N/A

Pressure Ulcer Risk Braden Scale Score: 23

Neurological

General Survey: Appears to be reported age, alert and oriented x 3, facial features symmetric,
no signs of acute distress

Level of Consciousness: Alert☒ Lethargic☐ Other☐ GCS: 15

Oriented: Person☒ Place☒ Time☒ Intermittently Confused☐

Pupils: PERRLA Speech: Clear☒ Other☐:Description of Other

Sensory Deficits: Hearing☐ Vision☐ Taste☐ Smell☐

Hand grasps: Equally Strong☒ Weakness: Left☐ Right☐

Leg strength: Equally Strong☒ Weakness: Left☐ Right☐

Further Description: N/A

Head and Neck

Eyes: Redness☐ Drainage☐ EOM intact☒ Other: Eyes Other Description

Ears: Drainage☐ Other: Ears Drainage Other Description

Nose: Redness☐ Drainage☐ Nares Patent☒ Other Other Description

Throat/Mouth: Redness☐ Lesions☐ Bleeding☐ Other: Oral mucosa pink and moist,
no lesions visualized, uvula midline, no dental abnormalities visualized.

Further Description: No lymphadenopathy palpated, sinuses non-tender to palpation

Cardiovascular
3
Heart Rate:HR/min Rhythm: Regular☒ Irregular☐ Capillary Refill: < 2 secs.

Chest Pain: Y☒ N☐ Neck Vein Distention: ☐

Edema: Site N/A Pitting☐ Non-Pitting☐

Peripheral Pulses: Grade ( N= Normal, W= Weak, S= Strong)

Radial: L: N R: N Pedal: L:

N R: N

Other Pulse: Carotid L: N R: N

Further Description: Further CV Description

Respiratory

Rate: 18/min Rhythm: Regular☒ Irregular☐ Depth: Shallow ☐ Deep ☐ Normal ☒

Lung Sounds: R Normal L:Normal O2 Sat: 98%

O2 Type/Flow rate: Room air Resp. Treatments: N/A

Cough: Productive☐ Non-Productive☐ N/A Sputum: Color N/A Amount: N/A

Dyspnea☐ Dyspnea on Exertion☐ Orthopnea☐ Apnea☐ N/A

Further Description: N/A

Gastrointestinal

Abdomen: Soft☒ Firm☐ Flat☐ Distended☐ Pain☐ Tenderness☒ Upper left

quadrant

Bowel Sounds: Normoactive and present x 4 Last BM: Stool Characteristics: N/A
Incontinent to Stool: Y☐ N☒

Tubes/Ostomy: N/A

Further Description: N/A

Nutrition

Current Diet: Low sodium diet Restrictions/Modifications: High sodium, high fat, high sugar

Appetite: Good☒ Fair☐ Poor☐ Nausea / Vomiting☐

4
% of Food Eaten: Breakfast: N/A% Lunch: N/A%

Weight on admission: 90.9kg Current Weight: 90.9kg

Needs Assistance Feeding☐ Difficulty Chewing/ Swallowing:☐ Dentures☐ N/A

Tube feedings: Site N/A Type/Rate: N/A

Further Description: Patient found hiding a pack of chocolate M&M’s in bed.

Genitourinary

Urine: Color N/A Clarity N/A Odor N/A

Problems: Burning☐ Difficulty Voiding☐ Incontinent☐ Output Adequate☐ N/A

Contraceptive use N/A

Further Description: N/A

Mobility / Musculoskeletal

Gait: Not visualized ROM: Normal

Fatigue☐ Contractures☐ Paralysis☐

Needs Assistance: Bathing☐ Dressing☐ Toileting☐ Ambulating☐ Turning in bed☐

N/A

History of falls: Y☐ N☒ Falls Risk Score: N/A Assistive Devices: 1 person standby assist

Physical therapy: N/A

Further Description: Patient is self-care with 1 person stand by assist.

Pain/Discomfort

Location: Chest and LUQ abdomen Intensity: Approximately 6/10 Quality: Burning and
aching Duration: 1 day Intervention: Nitroglycerin patch 0.3mg/hour Further Description:
N/A

Social Support/ Psychosocial

Significant Others: N/A Relationship with family: N/A

Stress Management/ Coping: N/A

Major Changes or Traumatic Loss Recently: N/A

5
Counselor / Agency Help: N/A

Barriers to learning: Pain☐ Anxiety☐ Cognitive☐ Literacy☐ Language☐ Cultural☐

Deafness☐ Blindness☐ Other: Noncompliance with medications

Further Description: N/A

Self-perception/ Self-Concept
Description and feelings regarding self: N/A

Body changes / adjustment problems: N/A

Positive / negative feelings: N/A

Further Description: N/A

Community / Home Assessment

Current Occupation/retired occupation: Construction worker

Cultural Practices: N/A

Religion/Spiritual practices: Catholic

Further Description: N/A

Source of information: Patient☒ Chart☐ Family☐ Other: Other Source of Info

LAB TESTS
Test Normal Range (CHS Initial Today EXPLAIN the significance – not just high or low.
Lab) Value Date Date: How were they corrected?

Complete Blood Count

12
RBC 3.9-5.0 x10 /L 4.3 RBC Current RBC Significance
HGB 11.8-15.9 g/dL 15.5 HGB Current HGB Significance
HCT 36.0-47.0 % 39.0 HCT Current HCT Significance
WBC 4.1-10.7 x 109/L 5.8 CWBC Current WBC Significance
Seg. Neutrophils 38-80 % 40.1 Seg Neut Segmented Neutrophils Significance
Current
Lymphocytes 15-49 % 46.1 Lymphocytes Lymphocytes Significance
Current
Eosinophils 0-8 % 0.6 Eosinophils Eosinophils Significance
Current
Basophils 0-2 % 0.3 Basophils Basophils Significance
Current
Monocytes 0-13 % 12.9 Monocytes Monocytes Significance

6
 Current
Bands 0-8% Bands Bands Current Bands Significance
Initial
Platelets 150 – 400 x 109/L 170 Platelets Platelets Significance
Current
aPTT 24-36 seconds 38 aPTT Current High
PT 11.9-15.3 seconds 17 PT Current High
INR 0.8-1.1 INR Initial INR Current INR Significance
Metabolic Panel (Chemistry)
Sodium (Na+) 132-141 mmol/L 135 Na+ Current Na+ Significance
Potassium (K+) 3.6-5.2 mmol/L 3.8 K+ Current K+ Significance
Chloride (Cl) 97-107 mmol/L 105 Cl- Current Cl- Significance
Carbon Dioxide 21-32 mmol/L 25 CO2 Current CO2 Significance
Glucose 70-100 mg/dL 280 320 High
BUN 7-18 mg/dL 8 BUN Current BUN Significance
Creatinine 0.7-1.2 mg/dL 0.7 CK Current CK Significance
Calcium 8.5 - 10.1 mg/dL 8.7 Ca2+ Current Ca2+ Significance
Magnesium 1.6 - 2.0 mg/dL Mg2+ Mg2+ Current Ca2+ Significance
Initial
CK-mB 5-25 IU/L 24
Troponin 0-0.4 ng/ml 0.8 High
Urinalysis
Appearance/Color
pH 5.0-9.0 US pH Current UA pH Significance
Specific gravity 1.001 – 1.035 UA SG UA SG Current UA SG Significance
Initial
Occult Blood Negative UA Occult UA Occult UA Occult Blood Significance
Blood Blood Current
Initial
Ketones Negative UA UA Ketones UA Ketones Significance
Ketones Current
Initial
Glucose Negative UA UA Glucose UA Glucose SIgnificance
Glucose Current
Initial
Protein Less than 20 mg/dL UA Protein UA Protein UA Protein Significance
Initial Current
Bilirubin Negative UA UA Bilirubin UA Bilirubin Significance
Bilirubin Current
Initial
Other
ALT/AST 5-40 U/L / 7-56 U/L LFT Initial LFTs Current LFTs Significance
Triglycerides <150 mg/dL TG Initial TG Current TG Significance
Cholesterol <200 mg/dL Cholesterol Cholesterol Cholesterol Significance
Initial. Current

7
Blood Cultures Blood Blood Cultures Blood Cultures Significance
Cultures Current
Initial
Urine Cultures Urine Urine Cultures Urine Cultures Significance
Cultures Current
Initial
Sputum Cultures Sputum Sputum Sputum Cultures Significance
Cultures Cultures
Initial Current
Wound Cultures Wound Wound Cultures Wound Cultures Significance
Cultures Current
Initial

DIAGNOSTIC STUDIES

TEST DATE RESULT

EKG EKG Result
Date.
XRAY X-Ray Result

ULTRASOUND US US Result
Date
CT SCAN CT Abdomen- negative

MRI MRI Result

EEG EEG Result

ECHO 12/16/202 Study scheduled for later today.

0

8
 MEDICATIONS
(Copy page if needed. Include all patient medications.)

BRAND: Betimol, Istalol BRAND: Minitran, GoNitro

GENERIC: Timolol GENERIC: Nitroglycerin Patch

DOSE: One drop in both eyes twice a day DOSE: 0.3 mg/ hr topically

CLASSIFICATIONS, INDICATIONS, & ACTIONS: CLASSIFICATIONS, INDICATIONS, & ACTIONS:

Classifications: Beta-blocker
Indication(s): Ocular hypertension, glaucoma
Action(s): Reduces intraocular pressure
PRIORITY SIDE-EFFECTS AND BLACK BOX WARNINGS:
PSEs: wheezing, chest pain, trouble breathing, bradycardia, lightheadedness,
muscle weakness, numbness, severe stinging and burning after using eye
drops, eye swelling, redness.
BBWs: Asthmatic reaction, cardiac failure, obstructive pulmonary disease
NURSING IMPLICATIONS:
1. Monitor diabetic patients carefully. Systemic beta-blocking effects
can mask some signs and symptoms of hypoglycemia.
2. Don’t confuse timolol with atenolol. Don’t confuse Timoptic with
Viroptic.
3. Some patients may need a few weeks of treatment to stabilize
pressure-lowering response. Determine IOP after 4 weeks of
treatment.
Classifications: Therapeutic- vasodilator, antianginal Pharmacologic- nitrate
Indication(s): Angina, heart failure after MI, hypertension from surgery
Action(s): Reduces cardiac oxygen demand by decreasing left ventricular end-
diastolic pressure (preload) and, to a lesser extent, systemic vascular
resistance (afterload). Also increases blood flow through the collateral
coronary vessels
PRIORITY SIDE-EFFECTS AND BLACK BOX WARNINGS:
PSEs: Orthostatic hypotension, bradycardia, palpitations, weakness, nausea,
vomiting, headache, syncope
BBWs: N/A
NURSING IMPLICATIONS:
1. Closely monitor vital signs, particularly BP, during infusion, especially
in patient with an MI. Excessive hypotension can worsen ischemia.
2. Wipe off nitroglycerin paste or remove patch before administering
new one.
3. Don’t confuse nitroglycerin with nitroprusside or nitrofurantoin.
Don’t confuse Nitroderm with Nicoderm.

BRAND: Triple Antibiotic BRAND: Klor-Con

GENERIC: Neomycin-Bacitracin-Polymixin GENERIC: potassium chloride

DOSE: Ointment to bilateral lower eyelids every 8 hours DOSE: 10 mEq by mouth daily

15
CLASSIFICATIONS, INDICATIONS, & ACTIONS:
Classifications: Opthalmic steroids with anti-infectives
Indication(s): inflammation and risk for bacterial infection or actual bacterial
infection
Action(s): Reduces inflammatory response and fights off bacterial infections
PRIORITY SIDE-EFFECTS AND BLACK BOX WARNINGS:
PSEs: itching, swelling, conjunctival erythema, anaphylaxis, elevated IOP,
cataract formation, reduced wound healing, development of glaucoma.
BBWs: N/A
NURSING IMPLICATIONS:
1. Inform patients it is for external use only.
2. Educate patient on proper application of the medication; do not
touch the tip of the tube to the eye.
3. Do not take if pregnant as it may have a teratogenic effect.
CLASSIFICATIONS, INDICATIONS, & ACTIONS:
Classifications: Therapeutic- potassium supplements, pharmacologic-
potassium salts
Indication(s): hypokalemia
Action(s): replaces potassium and maintains potassium level
PRIORITY SIDE-EFFECTS AND BLACK BOX WARNINGS:
PSEs: paresthesia, confusion, weakness, flaccid paralysis, arrhythmias, heart
block, cardiac arrest, hypotension, hyperkalemia, nausea, vomiting,
abdominal pain, diarrhea, respiratory paralysis.
BBWs: N/A
NURSING IMPLICATIONS:
1. Monitor continuous ECG and electrolyte levels during therapy.
2. Patients at increased risk for GI lesions when taking oral potassium
include those with scleroderma, diabetes, mitral valve replacement,
cardiomegaly, or esophageal strictures, and elderly or immobile
patients.
3. Monitor renal function
16
BRAND: Lasix
GENERIC: furosemide
DOSE: 20 mg IV daily
CLASSIFICATIONS, INDICATIONS, & ACTIONS:
Classifications: Therapeutic- antihypertensive, pharmacologic- loop diuretics
Indication(s): edema and hypertension
Action(s): Inhibits sodium and chloride reabsorption at the proximal and distal
tubules and the ascending loop of Henle
PRIORITY SIDE-EFFECTS AND BLACK BOX WARNINGS:
PSEs: vertigo, headache, paresthesia, weakness, fever, orthostatic
hypotension, thrombophlebitis, yellowed vision, tinnitus, pancreatitis,
hypokalemia, hypocalcemia, hypomagnesemia
BBWs: Drug is potent diuretic and can cause severe diuresis with water and
electrolyte depletion. Monitor patient closely and adjust dose carefully.
NURSING IMPLICATIONS:
4. Monitor weight, BP, and pulse rate routinely with long-term use.
5. Watch for signs of hypokalemia, such as muscle weakness and
cramps.
6. Monitor elderly patients, who are especially susceptible to excessive
diuresis, because circulatory collapse and thromboembolic
complications are possible.
BRAND: Novalog
GENERIC: insulin
DOSE: Based on sliding scale
CLASSIFICATIONS, INDICATIONS, & ACTIONS:
Classifications: Therapeutic- antidiabetic, pharmacologic- insulins
Indication(s): to improve glycemic control
Action(s): Lowers blood glucose level by stimulating peripheral glucose uptake
by binding to insulin receptors on skeletal muscle and in fat cells and by
inhibiting hepatic glucose production; also inhibits lipolysis and proteolysis,
and enhances protein synthesis.
PRIORITY SIDE-EFFECTS AND BLACK BOX WARNINGS:
PSEs: seizures, hypoglycemia, hypokalemia, anaphylaxis
BBWs: Inhaled insulin is contraindicated in patients with chronic lung disease,
such as asthma or COPD, as acute bronchospasm has been observed in these
patients.
NURSING IMPLICATIONS:
4. Closely monitor patients also taking other medications as other drugs
can mask signs and symptoms of hypoglycemia or cause an increase
or decrease in blood glucose level.
5. Increase frequency of glucose monitoring when initiating therapy or
when changes in insulin strength, dosage, manufacturer, or type or
method of administration are made. Changes may affect glycemic
control and increase risk of hypoglycemia.
6. Closely monitor patients at risk for DKA from acute illness or
infection; consider changing from inhaled product to alternative
route of insulin delivery.
17
BRAND: Synthroid
GENERIC: levothyroxine sodium
DOSE: 100 mcg by mouth daily
CLASSIFICATIONS, INDICATIONS, & ACTIONS:
Classifications: Therapeutic- thyroid hormone replacements Pharmacologic-
thyroid hormones.
Indication(s): hypothyroidism
Action(s): Synthetic form of thyroxine that affects the growth of tissues,
energy expenditure, and the turnover of all substrates.
PRIORITY SIDE-EFFECTS AND BLACK BOX WARNINGS:
PSEs: arrhythmias, cardiac arrest, hypertension, heart failure, MI
BBWs: Don’t use either alone or with other therapeutic agents for
treatment of obesity or for weight loss.
NURSING IMPLICATIONS:
7. In patients with CAD who must receive thyroid hormone, observe
carefully for possible coronary insufficiency.
8. Long-term therapy causes bone loss in premenopausal and
postmenopausal women. Consider a basal bone density
measurement, and monitor patient closely for osteoporosis.
9. Patients taking levothyroxine who need to have 131I uptake studies
performed must stop drug 4 weeks before test.
BRAND: Heparin sodium injections
GENERIC: heparin sodium
DOSE: 5000 subcutaneously every 8 hours
CLASSIFICATIONS, INDICATIONS, & ACTIONS:
Classifications: Therapeutic- anticoagulants, pharmacologic- anticoagulants
Indication(s): thromboprophylaxis, DVT, PE, venous thrombosis
Action(s): Accelerates formation of antithrombin III–thrombin complex and
deactivates thrombin, preventing conversion of fibrinogen to fibrin
PRIORITY SIDE-EFFECTS AND BLACK BOX WARNINGS:
PSEs: thrombocytopenia, hyperkalemia, hemorrhage
BBWs: N/A
NURSING IMPLICATIONS:
7. Draw blood for aPTT 4 to 6 hours after subcut dose.
8. There is the potential for delayed onset of HIT, a serious antibody-
mediated reaction resulting from irreversible aggregation of platelets.
HIT may progress to the development of venous and arterial
thromboses, a condition referred to as heparin-induced
thrombocytopenia and thrombosis (HITT). Thrombotic events may be
the initial presentation for HITT, which can occur up to several weeks
after stopping heparin therapy. Evaluate patients presenting with
thrombocytopenia or thrombosis after stopping heparin for HIT and
HITT.
9. Avoid IM injections of other drugs to prevent or minimize
hematoma.
18
BRAND: InFed

GENERIC: iron dextran

DOSE: 0.5 mL IM daily

CLASSIFICATIONS, INDICATIONS, & ACTIONS:

Classifications: Therapeutic- iron supplements Pharmacologic- hematinics
Indication(s): iron deficiency
Action(s): Provides elemental iron, an essential component in the formation
of Hb

PRIORITY SIDE-EFFECTS AND BLACK BOX WARNINGS:

PSEs: seizures, bradycardia, cardiac arrest, shock, bronchospasm, respiratory
arrest, anaphylaxis.
BBWs: Fatal anaphylactic reactions have been reported. Fatal reactions
have occurred when the test dose was tolerated. Patients with history of
drug allergy may be at increased risk. Give only when indications have
been clearly established.

NURSING IMPLICATIONS:
10. Don’t give iron dextran with oral iron drug.

11. Monitor Hb level, hematocrit, and reticulocyte count.

12. Maximum daily dose should not exceed 2 mL undiluted iron dextran.

19
 PATHOPHYSIOLOGY CONCEPT MAP
Focused Physical Exam Components for Diagnosis
Pathophysiology and Associated Factors Risk
Signs of systemic hypoperfusion such as hypotension,
thrombotic occlusion of a coronary vessel caused tachycardia, impaired cognition, pulmonary crackles,
by rupture of a vulnerable plaque. Ischemia pain, radiating pain
induces profound metabolic and ionic perturbations
in the affected myocardium and causes rapid
depression of systolic function. Associated factors:
HTN, high cholesterol, obesity, diabetes, family
history, tobacco use, and age.

Medical Diagnosis
List
Myocardial Infarction (MI)
Expected Abnormal Labs/Diagnostic Studies
Expected Medications (Be Specific)
Troponin, ckmb, myoglobin
Morphine, nitroglycerin, heparin
EKG, stress test

Expected Medical and Surgical Treatment

Potential Complications/Adverse Effects
Thrombolysis, balloon angioplasty
Pericarditis, heart failure, disturbance of heart
rate, rhythm and conduction.

List all Actual and Potential Patient Specific Nursing Diagnoses

Acute pain related to tissue ischemia as evidenced by chest pain.

Activity intolerance related to imbalance between myocardial oxygen supply and demand as evidenced by exertional angina.

Risk for decreased cardiac output related to reduced preload/increased SVR. 20

 INDIVIDUALIZED NURSING CARE PLAN
NURSING DIAGNOSIS (Pick the two priority diagnoses based on your concept map)
1. Acute pain related to tissue ischemia as evidenced by chest pain
2. Risk for decreased cardiac output
PLANNING: Outcome Goals NURSING INTERVENTIONS SCIENTIFIC RATIONALE
(1 short term goal and 1 long term goal for each (3 for each diagnosis) (for each intervention, provide scientific rationale with
diagnosis. Make them measurable outcome Remember to base interventions on diagnosis and outcome author/authors name next to each rationale)
goals) goals
The patient will: The student nurse will: (Assess, Do, Teach)
1. Pain medications, especially narcotics, can help
1A: Pt. will verbalize relief/control of chest pain 1. Administer pain medications as ordered. alleviate pain and provide relief to the patient.
within appropriate time frame for administered 2. Check vital signs before and after narcotic medication.
2. Hypotension and respiratory depression can
medications. 3. Monitor and document characteristic of pain, noting verbal
occur as a result of narcotic administration.
reports, nonverbal cues (moaning, crying, grimacing,
These problems may increase myocardial
1B: Pt will display reduced tension, relaxed restlessness, diaphoresis, clutching of chest) and BP or heart
rate changes. damage in presence of ventricular insufficiency
manner, ease of movement.
4. Evaluate quality of pulses on both pulse points. (Vera, 2020).

2A: Pt will demonstrate an increase in activity 5. Monitor heart rate and rhythm. Document dysrhythmias via 3. Variation of appearance and behavior of
patients in pain may present a challenge in
tolerance. telemetry.
assessment. Most patients with an acute MI
6. Measure cardiac output and other functional parameters as
appear ill, distracted, and focused on pain.
2B: Pt will maintain hemodynamic stability, for appropriate.
4. Decreased cardiac output results in diminished weak
example: BP, cardiac output within normal
or thready pulses. Irregularities suggest
range, adequate urinary output, decreased
dysrhythmias, which may require further evaluation
frequency/absence of dysrhythmias
and monitoring.
5. Heart rate and rhythm respond to medication,

activity, and developing complications.

Dysrhythmias (especially premature ventricular

21
 contractions or progressive heart blocks) can
compromise cardiac function or increase
ischemic damage. Acute or chronic atrial flutter
may be seen with coronary artery or valvar
involvement and may or may not be
pathological.
6. Sufficient cardiac output helps keep blood
pressure at the levels needed to supply
oxygen-rich blood to your brain and other vital
organs (Staff, 2019).

EVALUATION OF OUTCOME GOALS

(Were goals met? Explanation of met outcome goals. If outcome goal unmet, explain why unmet)
1. Goal met, patient verbalized relief from chest pain after administration of nitroglycerin path.
2. Goal met, patient seemed less restless and decreased grimacing.

1. Goal unmet as this is a risk diagnosis, patient is able to perform activities without assistance.
2. Goal unmet as this is a risk diagnosis, patient will maintain levels over a period of time if treatment plan is adhered to.

REFERENCES

Vera, M. (2020). 7 Myocardial Infarction (Heart Attack) Nursing Care Plans. Nurse Labs. https://nurseslabs.com/7-myocardial-infarction-heart-attack-nursing-
care-plans/

Staff. (2019). Cardiac Output. Michigan Medicine. https://www.uofmhealth.org/health-library/tx4080abc

Thomas Edison State University

W. Cary Edwards School of Nursing
Accelerated BSN Program
22

Student Name: FN LN
Patient Initials: PT Initials
Category
Background
Information
(Clinical packet)
Prioritization of
Nursing Diagnosis
(2 Diagnoses)
Short-term Outcome
Goals
(1 for each diagnosis)
Long-term Outcome
Goals
(1 for each diagnosis)
Interventions
(Assess, Do, Teach)
(3 interventions for
each diagnosis)
Scientific rationale for
interventions
(need to be from
nursing books or
4 3
The patient’s background
information is completed. All
relevant information is included
from clinical packet.
The nursing concept map
addressed the 2 priority nursing
diagnoses. The nursing
diagnoses are correctly stated
using NANDA terminology.
Short-term outcome goal
identified for each diagnosis. The identified but one of the
outcome goals are
patient-oriented and include a
time frame and are measurable.
Long-term outcome goal
identified for each diagnosis. The are patient-oriented but is
goals are
patient-oriented, includes a time
frame, and is measurable.
Interventions are sufficient to
address each nursing diagnosis.
Address what the nurse will
assess, do, and teach; and are
Specific (what, when, where,
how).
Individualized to the patient.
Scientific rationale for each
intervention is identified.
Rationales are accurate.
Clinical Grading Rubric
The patient’s background
information is completed but
some information is missing.
The nursing diagnoses selected
are the priority but one or both
are stated inaccurately.
Relevant outcome goals are
required elements is missing.
The long-term outcome goals
missing one component.
Interventions are sufficient to
address each nursing diagnosis.
Address what nurse will assess,
do, and teach.
Specific (what, when, where,
how).
Are not individualized to the
patient.
Scientific rationale for each
intervention is identified. One
rationale lacks accuracy.
2 1
The patient’s background
information is incomplete.
The nursing diagnoses selected
are the priority but is not
NANDA appropriate.
Relevant outcome goals are
identified but two of the
required elements are missing.
The long-term outcome goals
are patient-oriented but are
missing more than one
component.
One or more interventions do
not address what the nurse will
assess, do, and teach, and are
not specific or individualized to
the patient.
Scientific rationale for each
intervention is stated but lacks
accuracy in more than one area.
SCORE
The patient’s background Score
information was not
completed or missing multiple
pertinent background
information.
The nursing diagnoses Score
selected are not the priority.
The outcome goals are not Score
relevant to the nursing
diagnosis.
The goals are not relevant to Score
the nursing diagnosis.
Interventions do not address Score
either nursing diagnosis.
Scientific rationale are not Score
provided.
23
 journals)

Evaluation Explanation about why outcome Explanation about why Addresses outcome goals met or Evaluation was not Score
(Outcomes achieved) goals were met/unmet includes outcome goals were met/unmet not met but not details provided. completed.
specific data on effectiveness of with minimal data on
interventions. effectiveness of interventions.

References Sources are properly cited using Sources cited with minor errors Sources cited with major errors No sources are provided. Score
APA format. At least 2 nursing in APA citation. with APA citation.
sources: books, journal articles

Format No errors in grammar, spelling, No more than two errors in 3-5 errors in grammar, spelling, More than 5 errors in Score
punctuation. grammar, spelling, punctuation. grammar, spelling, or
punctuation. punctuation.

A score of 29/36 or better is required to pass. Areas scoring 2 or below, need to be redone and submitted within 2 days. Total Score:
0/36

Comments: Clinical Instructor Comments

X
Clinical Educator

X
Student Signature

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