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Student Name:
Jason Villavicencio
Date of Care:
11/05/13
Primary Diagnosis:
Acute on Chronic Systolic Heart Failure
Co-morbidities:
Difficulty in walking
Muscle weakness (generalized)
Atrial Fibrillation
Unspecified disorder of kidney and ureter
Unspecified essential hypertension
Coronary atherosclerosis unspecified type vessel native/graft
Preliminary Integrated Pathophysiology primary diagnosis (what is going on with your client at the cellular
level for the health condition, due before clinical shift; (typed 1-3 pages with APA formatting). Explain how
your clients primary diagnosis, co-morbidities, medications and labs interrelate.
Data Collection (Record exactly what is written on the personal information sheet [aka Kardex]. Any
assessment/elaboration should be made on the assessment sheet):
Diet (Type): Regular diet/Regular texture
IV (Fluid type, rate, access type): No
I&O (MD order/Nursing Order/Frequency): No
CBG (Yes/No, frequency): No
Fall Risk/Safety Precautions (Yes/No): Yes/Bedrails
Activity (Patients activity level ): 1PerAssist with
ADLs
Wound Care (Yes/No): Yes
Oxygen (Yes/No, Delivery method, how much): No
Drains (Yes/No, Type): No
Last BM: 11/5/13
Other Tubes: No
ASSESSMENTS
(Include Subjective & Objective Data)
Integumentary:
Skin: LE bilateral edema +3, smooth, no hair, uniform
color normal for age; pedal cyanosis, nails thick, dark
green; wound dressing bilateral unable to assess.
LUE ecchymosis, wound dressing X3 unable to assess,
X1 scabbing quarter size on L forearm, X2 scabbing
wound pea size forearm. UE bilateral cold cyanotic,
nails thick/brittle with longitudinal ridges, clubbing,
capillary refill unable to assess due to integrity.
Thorax color appropriate for race, no hair, scare on
sternum 8in. in length. Abdominal ecchymosis LUQ
10inX4in. Hair on scalp evenly distributed color
appropriate for age, mobile, non-tender. Open wound
on coccyx 4cmX3cm.
Eyes/Ear/Nose/Throat:
Wears classes reading and distance, color vision intact
Diminished visual field, eyes parallel, light reflex
symmetrical, Extraocular motion intact OU, no
wandering, + corneal reflex, PERRLA, pupil 3-5mm
Ears presbicusis hearing aids bilaterally, positive
Romberg, external ear non-tender, no lesions
Nose symmetrical moist, pink septum intact hair
appropriate for age.
Cardiac:
Carotid pulsation large, bounding, visible in neck
Elevated JVP, Giant A wave
Bruit, Diminished S1,
Musculoskeletal:
UE bilaterally ROM Full strength +3
Neck AROM full
Assist with ambulation and transfers
Positive Romberg
Muscle weakness in LE bilaterally unable to perform
ROM
Fingers and thumb swollen tender, no deformities
Propulsive Gait
Genitourinary:
Gastrointestinal:
Pain in ULQ dull Pt states from fall 2 on 1-10 pain
scale
BT auscultated in all 4 quadrants, gastric sounds <15
sec
Neurological / Psychosocial
A/O x3
CURRENT MEDICATIONS
List ALL regularly scheduled and prn medications scheduled on your client.
(Due morning of clinical)
Generic &
Trade Name
Classification
Dose/Route/
Rate if IV
Onset/
Peak
Intended
Action/Therapeutic
use. Why is this
client taking med?
Fever reduction
Adverse
reactions (1
major side
effect)
Elevation of
ALT/AST
Acetaminoph
en
(Tylenol)
Nonnarcotic
analgesic
325mg 2
tabs Q4H
PRN if temp
over 100.4
IpratropiumAlbuterol
Bronchodilator
s
Lorazepam
(Ativan)
SedativeHypnotic
Nitroglycerin
Antianginal/
nitrate
vasodilator
Doxycycline
Hyclate
Antibiotic
Potassium
Chloride
Electrolytic
replacement
0.5/2.5
(3)mg/3ml
neb PO PRN
SOB 3ml
q4hrs
0.5mg
Tablet
Once daily
Bedtime PO
PRN
0.4mg 1
sublingual
first sign
attack,
repeat Q5
min (no
more than 3
within 15
mins) PRN
100mg
Tablet PO
BID
20 mEq
Extended
O:
within
1H
P:0.52H
O:515min
P:0.52h
Relieves bronchial
constriction.
Elevation of HR;
cough
P: 2h
Insomnia
Hypertension or
Hypotension
O: 2
min
Prophylaxis or
treatment of
angina
Early MI,
increased ICP
(sustained
release formcontraindication
is glaucoma)
P: 1.54h
Cellulitis
N/V, diarrhea
Hypokalemia
Cardiac
depression,
solution
Prednisone
Furosemide
Adrenal
corticosteroid
Release 1
Tablet PO
BID with or
after meals
20mg Tablet
PO daily
Electrolytic
and water
balance agent
80mg Tablet
1 PO BID
with food
Hydralazine
HCL
Vasodilator
Losartan
Potassium
(Cozaar)
Angiotensin II
Receptor
Metoprolol
Tartrate
bradycardia, or
arrest.
P:1-2h
P: 6070min
O: 3060min
25mg Tablet P: 2hrs
1 PO QID
O: 20with food
30min
25mg
P: 6hrs
Tablets 2 PO
once a day
(Do Not
Give if HR
above 50
and or Sys.
BP below
90)
Cardioselective 50mg Tablet
P:
; Bata2 PO BID
1.5hrs
Adrenergic
O:
Antagonist;
15min
Antihypertensi
ve; Anianginal
Vasculitis
CHF, N/V,
insomnia,
Hypokalemia
Hypokalemia,
dehydration
Promotes
vasodilation which
increases blood
flow to the
extremities.
Hypertension
Hypotension,
tachycardia,
heart
palpitations
Upper
respiratory
infection
Monitor VS.
Reduce edema
from CHF,
Arrythmias
Severe
bradycardia or
hypotension
Edema associated
with CHF
DIAGNOSTIC TESTING
Include pertinent labs [ABGs, INRs, cultures, etc] & other diagnostic reports [X-rays, CT, MRI, U/S,
etc.]
NOTE: Adult values indicated. If client is newborn or elder, normal value range may be different.
Date
Lab Test
Patient Values/
Interpretation as related to Pathophysiology
Normal Values
Date of care
cite reference & pg #
Sodium
Did not find Labs
135 145 mEq/L
Potassium
3.5 5.0 mEq/L
Chloride
97-107 mEq/L
Co2
23-29 mEq/L
Glucose
75 110 mg/dL
BUN
8-21 mg/dL
Creatinine
0.5 1.2 mg/dL
Uric Acid Plasma
4.4-7.6 mg/dL
Calcium
8.2-10.2 mg/dL
Phosphorus
2.5-4.5 mg/dL
Total Bilirubin
0.3-1.2 mg/dL
Total Protein
6.0-8.0 gm/dL
Albumin
3.4-4.8gm/dL
Cholesterol
<200-240 mg/dL
Alk Phos
25-142 IU/L
SGOT or AST
10 48 IU/L
LDH
70-185 IU/L
CPK
38-174 IU/L
WBC
4.5 11.0
RBC
male: 4.7-5.14 x 10
female: 4.2-4.87 x 10
HGB
male: 12.6-17.4 g/dL
female: 11.7-16.1 g/dL
HCT
male: 43-49%
female: 38-44%
MCV
85-95 fL
MCH
28 32 Pg
RDW
11.6-14.8%
Platelet
150-450
DIAGNOSTIC TESTING
Date
UA
Normal
Range
Results
Color/Appearance
pH
Spec Gravity
Protein
Glucose
Ketones
Blood
Date
Other
(PT, aPTT, PTT,
INR, ABGs,
Cultures, etc)
Normal
Range
Results
Date
Radiology
X-Rays: 1 Chest
View
Scans: CT
Head/Brain
EKG-12 lead
Telemetry
Other
Results
Interpretation as related to
Pathophysiology cite reference &
pg #
Did not find in chart
Interpretation as related to
Pathophysiology cite reference &
pg #
Interpretation as related to
Pathophysiology cite reference &
pg #
Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as evidenced by (AEB).
Problem #1: Impaired Skin integrity r/t trauma AEB open wounds
Desired Outcome: Sustain current skin integrety
Nursing Interventions
Client Response to Intervention
1. Monitor wound area for color change, redness, swelling,
1. Was unable to assess wound, dressings
warmth and pain.
changed before I was able to get on floor.
2. Educate pt in the need for assistance with transfers and
ambulation.
Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed):
I was unable to assess wound because of treatment timing. I would communicate with attending nurse for
wound care to assess wound. The pt did use call light for assistance with transfers and ambulation.
Problem #2: Ineffective tissue perfusion r/t CHF AEB peripheral edema
Desired Outcome: Decrease level of peripheral edema by end of AM shift
Nursing Interventions
Client Response to Intervention
1. Elevate lower extremities to promote perfusion
1. Kept lower extremities elevated while pt
rested.
2. Monitor VS and peripheral pulse for changes
2. VS showed no abnormal changes, peripheral
pulse demonstrated no change
3. Educate pt about importance of elevating legs and
3. Pt verbalized the importance by stating, yes, I
watching for skin break down.
understand what you are saying
Evaluation: Peripheral edema was not reduced by end of shift. My time from was unrealistic for the outcome.
Problem #3: Fatigue r/t difficulty sleeping AEB pt stating, I cant sleep most nights, so Im usually pretty tire
during the day.
Desired Outcome: Pt demonstrating increased energy by end of AM shift.
Nursing Interventions
Client Response to Intervention
1. Monitor pt VS between activities
1. No unexpected changes
2. Encourage pt to get rest between actives (OT, meals,
2. Pt rested in recliner in between physical
toileting)
activity
3. Assist pt with ADLs as necessary, encouraging
3. Pt verbalized appreciation by stating, Thank
independence without causing exhaustion.
you for the help
Evaluation: Pt showed an increased interest in physical activity with his participation in PT.