N4810 Clinical Paperwork Rev 11/6/13

CSU, STANISLAUS B.S.N.

CLINICAL PLAN OF CARE
Patient Data
Student __Bobbie Chahal

Date of Care 10/2/14-10/3/14

Room Number 86A Code Status: FULL

Pt. Initials ___Gender:M Age___ Height 511 Weight_76.5 kg BMI 23.5 % (Normal: 18.5-24.9%) Spirituality Catholic_ Ethnicity Mexican
American
Admitting Diagnosis: _Acute Respiratory Failure, Aspiration Pneumonia,Dental Abscess
Vital Signs: Temp _37 C HR _85 RR 20_ B/P 91/49__ O2 Sat 100 % Pain Scale & Scale Type: _Nonverbal Scale
History related to this admission _Dental infection inflammation airway obstruction_respiratory failureArtery nicked during Tracheostomy
placement intubated on ventilator in SICU
Past Medical History __No past medical issues in chart
Admit Date 10/29/14 POD Tracheostomy attempted on date of 10/28/14:
Surgical History & Date No dates available
MD(s) Rahhal MD, Suhail
Diet _NPO/no feedings ordered
Activity Bedrest
Foley Indwelling Foley
Feeding Tube & Rate _OG tube insterted but clamped
Advance Directive: Yes. Parents medical power of attorney
Drains/ Tubes Orogastric tube,Foley Catheter, Endotracheal tube
Isolation Contact precautions Standard
VS Freq Q4H
Glucose Monitoring Q6H DVT Prophylaxis Sequential compression device
Vascular Access: Peripheral IV: Left Antecubital saline lock 22 g
Central IV Left Internal Jugular, triple lumen
PCA/Epidural None Telemetry & Rhythm ECG 12 lead (Normal sinus rhythm)
IV Site: Peripheral IV Left Antecubital saline lock 20G, L Wrist 18G, R Hand 20G
Central IV R Radial, triple lumen. (Arterial line)
IV Solution & Rate: 0.9% NS 1,000 mL over 6.7 hr RATE: 150 mL/hr
Safety Considerations Fall Risk Restraints Bilateral Arm restraints
Dressing Changes & Frequency None Scheduled Procedures Extubation planned for once inflammation decreases
Procedures done this admission Arterial line placement, Intubation, Foley present on admission, OG tube placement
Oxygen Ventilator: Fi02:100%
Respiratory Treatment: Albuterol PRN (RT)
Vent Settings: Assist Control PEEP 5, Respiration Rate Set: 20, Tidal Volume-Mecahnical (500), FiO2: 100%)
Advanced Hemodynamic Monitoring & Values: Arterial Line (R Radial)
Name of test

Normal

Result 1
(latest)

Result 2

Rationale

N4810 Clinical Paperwork Rev 11-6-2013

pCO2

35-45

41.9

42.8

PO2

80-100

146 (H)

228 (H)

pCO3

22-26

22.9

26.7 (H)

pH

7.35-7.45

7.37

7.41

Carbon dioxide of
arterial blood/increases
to balance an alkaline
state/ this is like the acid
of blood
Oxygenation of Arterial
blood
Bicarbonate in blood
(increases in an acid
state/ this is the base of
blood)
Acid base balance

IV Drips Medications Dosage & Rate: If tubing is microtubing = 60 drop factor

1. Piperacillin-tazobactam (ZOSYN)

3.375 g=15 mL, IV Piggyback, Q8h, infuse over 4 hours

Running at 125 mL/hr 125 mL x 60 gtt/mL divided by 60 min = 125 gtt/minute

2. Vancomycin (VANCOCIN) 1,000 mg in NS 500 mL, IV piggyback, Q12h
Infuse over 90 min
Running at 333 mL/hr 333 mL x 60 gtt/mL divided by 60 min = 333 gtt/minute
3. Dexmedetomidine (PRECEDEX) 200 mg in NS 50 mL, IV, titrate by 0.1 mcg/kg/hr
Running at 50 mL/hr 50 mL x 60 gtt/mL divided by 60 min = 50 gtt/minute
4. Levofloxacin (LEVAQUIN) Levofloxacin (LEVAQUIN)

750 mg=150 mL

IV Soln, IV Piggyback, Q24h, infuse over 90 min

Running at 100 mL/hr 100 mL x 60 gtt/mL divided by 60 min = 100 gtt/minute

Notes on Pathophysiology:
Acute Respiratory Failure: (hypoxia) not enough oxygen passes from the lungs into the blood/ (hypercapnia) Lungs not removing enough carbon
dioxide
Dental Abscess: an abscess is a tender mass that is full of pus and debris. It is different from an infection because antibiotics are not enough to treat
it. An abscess must be opened and drained in order for it to heal. An untreated abscess in the retropharyngeal region can eventually cause an airway
obstruction. Some symptoms a patient can present with are: stridor, drooling, high fever, sore throat, dysphagia, and trismus (contraction of the
muscles used to chew) which can prevent the patient from opening his mouth. Because a dental abscess can produce respiratory distress or failure,
N4810 Clinical Paperwork Rev 11-6-2013

securing the airway with a tracheal tube or an endotracheal tube is crucial. Treatment includes: Obtaining a culture, giving antibiotics, pain control,
and surgical drainage if it does not drain on its own. In this patients case, the abscess eventually caused an airway obstruction which then required
an artificial airway to be established with the endotracheal tube since tracheal tube insertion did not work out. The plan is to extubate patient once
inflammation decreases to a level at which the airway is patent and clear enough for patient to be able to breathe effectively.
CALIFORNIA STATE UNIVERSITY, STANISLAUS
MEDICATION WORKSHEET
Medication
Generic & Trade Name
Dose, Route, Frequency
Dexmedetomidine
(PRECEDEX)
400 mcg in NS 100 mL/ 4
mcg/mL, IV
Start at 0.4 mcg/kg/hr.
Titrate by 0.2 mcg/kg/hr
RASS GOAL: -2
MAX dose:1.4 mcg/kg/hr

Mechanism of Action
Classification
A selective alpha-adrenergic
agonist with sedation effects
Sedative/hypnotic

Vancomycin (VANCOCIN)
1,000 mg, injection, IV
Sticks onto bacterias cell wall,
piggyback, Q12h
causing cell death
Infuse over 90 min
Anti-infective
For trough level, get blood
draw 30 min before infusion

Vanco level:
Goal Trough: 10-15 Trough
due @11/1 @2030

Patient-Specific Rationale

Sedation of patient needed

while intubated

Treatment for pneumonia

Treatment for dental infection

Nursing Considerations
(Assessment implications, side effects, reasons
to hold med, administration rate, etc)
-Assess his level of sedation using RASS
(RASS goal is -2)
-Monitor ECG and BP
(Use Atropine IV if toxicity/overdose)
-Side effects: sinus arrest,bradycardia,
hypotension, nausea, vomiting, fever, hematuria
hypoxia
-Assess the infection (VITAL SIGNS, WBC,
SPUTUM CULTURE)
-Monitor BP
-Check urine (if it is pink or cloudy
nephrotoxicity!)
-Check for superinfection (black, furry tongue,
vaginal itching/discharge, loose/foul stools)
Assess for anaphylaxis (Keep resuscitation
equip. near and epinephrine, an antihistamine)
-Check bowel pattern (blood in stools
pseudomembranous colitis)
Keep checking renal function
-Trough level should not be more than 10
mcg/mL or 15-20 mcg/mL
-Side effects: anaphylaxis, hypotension, nausea,
vomiting, phlebitis, leukopenia, rashes,
nephrotoxicity, ototoxicity, back and neck
N4810 Clinical Paperwork Rev 11-6-2013

pain,red man syndrome (with rapid infusion),

superinfection.
Methylprednisolone
(SOLUMEDROL)
60 mg=1.5 mL, Injection,
IV Push, Q6h
*Rate: since it is <1.8/kg
and <125/dose: IV push
over 1-3 minutes.

Corticosteroid
(systemic)/antiasthmatic
Decreases inflammation and
normal immune response

Propofol 200 mg/20 mL

infusion
1,000 mg dose in 100 mL IV
TITRATE
Start at 10 mcg/kg/min
Q5 minute TITRATE
RASS GOAL: -2

general anesthetics
mechanism of action is
unknown. However, it does
produce amnesia and is also
referred to as a short acting
hyponotic

Will suppress inflammation in Assess for signs of adrenal insufficiency

the airway to help keep
(hypotension,
airway open
weight loss, weakness, nausea, vomiting,
anorexia, lethargy, confusion, restlessness)
-Monitor intake and output ratios and daily
weights.
-Observe for peripheral edema: steady weight
gain, rales/crackles, or dyspnea
-Side effects: CNS depression, hypertension
peptic ulcers
Will keep him sedated while
he is intubated

-Assess for sedation level

-Assess RR, HR, BP,
-Decrease sedation and assess Neuro function
-Monitor for Propofol Infusion Syndrome:
Metabolic acidosis, hyperkalemia,
hepatomegaly, renal failure, cardiac failure
-Toxicity? Check RR, HR, BP. Maintain airway.
In case of hypotension IV fluids,
respositioning, vasopressors!
-Side effects: dizziness, headache, apnea,

bradycardia, hypotension, hypertension,

burning, pain, stinging,
coldness, numbness, tingling at IV site, involuntary
muscle movements, discoloration of urine (green),
fever

N4810 Clinical Paperwork Rev 11-6-2013

Fentanyl (SUBLIMAZE)
10 mcg=1mL,
NS 1,000 mcg
100 mL, IV Titrate
Start at 25 mcg/hr
Titrate by 2.5 mcg/hr
Q15 minutes
Goal RASS: -2
MAX: 200 mcg/hr

Opioid agonist
Sticks to the opiate receptors in
the CNS, which then decreases
perception of pain

Vecuronium 100 mg +
NaCl 0.9% 100 mL, IV
0.8 mcg/kg/min
1 mg/mL

Nondepolarizing neuromuscular used to keep his skeletal

blocking agent /Skeletal muscle muscle relaxed while
relaxant
intubated

-Assess for sign of malignant hyperthermia

-Monitor the degree of neuromuscular blockade
by using the peripheral nerve stimulator

Aims for the cholingergic

receptors at the motor end plate.

Side effects: Skeletal muscle weakness or

paralysis/muscle atrophy
-Assess infection (vital signs; appearance of
wound, sputum, urine, and stool; WBC
Side effects: Seizures, insomnia,
,arrhythmias
hyperglycemia,
hypoglycemia, phlebitis at IV
site

Levofloxacin
(LEVAQUIN)
750 mg=150 mL
IV Soln, IV Piggyback,
Q24h, infuse over 90 min

Piperacillin-tazobactam
(ZOSYN)
3.375 g=15 mL, IV
Piggyback, Q8h, infuse over
4 hours

Fluoroquinolones
Anti-infective
Stops bacterias DNA
synthesis death of susceptible
bacteria
extended spectrum penicillins
Piperacillin:
Sticks on to cell wall
membrane,
causing cell death.
Tazobactam:
Inhibits beta-lactamase, an
enzyme that can destroy
Penicillins increases
effectiveness of piperacillin

Decrease pain/helps with

sedation

Death of the susceptible

bacteria causing dental
infection/pneumonia

Fighting infection
(pneumonia)
Death of susceptible bacteria
Treatment for
pneumonia/dental infection

Toxicity? Use Naloxone (NARCAN) to reverse

respiratory. Use Atropine for bradycardia
-Nonverbal cues of pain: elevated HR, increased
RR, facial expression, body language
-respiratory rate and blood pressure
Side Effects: respiratory
Depression, arrhythmias, bradycardia,
circulatory depression, hypotension,
nausea/vomiting

-Assess patient for infection (vital signs;

appearance
of wound, sputum, urine, and stool; WBC)
-Check for allergies
-Side effects:seizures,
insomnia, lethargy, pseudomembranous colitis,
drug-induced hepatitis,
bleeding, leukopenia,
phlebitis at IV site

N4810 Clinical Paperwork Rev 11-6-2013

Potassium Chloride
10 mEq=100 mL IVPB
administered
IV Potassium Replacement
Protocol;
3.8-3.9 mEq/L: Give 10
mEq/1hr x 2 doses
3.5-3.7 mEq/: Give 10
mEq/1hr x 3 doses
3-3.4 mEq/L: Give 10
mEq/1hr x 4 doses
2.9mEq/L or less: Notify
physician. Give 10 mEq/1hr
x 5 doses, Recheck
potassium after every
infusion is complete.
Acetaminophen/hydrocodon
e
(Acetaminophen:Hydrocodo
ne = 325mg:5mg)
Suppository

Supplement of electrolytes
and minerals so that body
processes can continue
without problems. Because
mineral and electrolyte
kidneys are excreting urine
replacement
there needs to be a source of
electrolytes since he is not
Necessary to maintain acid-base eating
balance and electrolyte balance
Needed for many enzyme
reactions, transmission of nerve
impulses, contraction of
cardiac/skeletal/smooth muscle,
gastric function,
renal function, tissue synthesis,
and carbohydrate
metabolism.
antipyretics, nonopioid
Control of fever, control of
analgesics
pain
Stops the making of
prostaglandins that are
mediators of pain and fever,
primarily in
the CNS.

chlorhexidine topical 15
mL, mouthwash buccal,
q12h swab to each side of
buccal cavity
antiseptic antibacterial agents

Oral care to promote hygiene

and decrease risk of bacterial
growth in oral mucous
membranes decreases risk
of ventilator acquired
pneumonia

-Assess for hypo/hyperkalemia

-Monitor pulse, BP and ECG
Side effects: confusion, weakness, arrhythmia,
abdominal pain, diarrhea, nausea, vomiting

Pain: Assess type, location, and intensity prior

to and 3060 min following administration.
Fever: Assess fever; note presence of associated
signs (diaphoresis, tachycardia, and malaise).
Side Effects: hepatotoxicity, renal failure (high
doses/chronic use
Make sure to suction adequately after providing
oral care to prevent aspiration. Apply lip
moisturizer.

Additional meds:
Insulin Lispro SUBCUT Q6H Medium dose, Sodium Chloride (NaCl 0.9% flush 20mL, IN
LABORATORY DATA
LABS

Normal Range

RESULT
1
10/30/14
0631

RESULT 2
10/31/14
0631

RESULT 3
11/1/14
0631

Reason for abnormal lab values r/t

diagnosis & nursing implications

N4810 Clinical Paperwork Rev 11-6-2013

CBC

WBC

4-11

6.0

9.2

RBC

4.1-6

4.01 (L)

3.55 (L)

13.5 (H)

3.66 (L)
Hemoglobin

13.5-17.5

12.3 (L)

11.0 (L)

11.2 (L)

Hematocrit

40-50.4

36.1 (L)

31.4 (L)

32.6 (L)

PLT COUNT

130-400

137

180

217

CHEMISTRY
Sodium

136-145

139

143

144

Potassium

3.5-5.1

5.1

4.4

3.8

Elevated WBCs indicate the

activation of the bodys immune
system to fight infections (dental
infection and pneumonia) Keep an eye
on this to assess for sepsis!
RBC is low and pts hemoglobin and
hematocrit is also low which suggests
that the low hemoglobin has halted
RBC production.
Low Hemoglobin r/t low oxygen
carrying ability by blood
This is the ratio of blood cells to
plasma. Low hematocrit indicated low
red blood cells compared to the
plasma in the blood
Platelets give blood the ability to clot.
Low platelets indicate a decreased
coagulation capacity of blood
increased risk of bleeding
Necessary to maintain fluid volume,
blood volume, muscle and nerve
function. An imbalance causes
problems in all of these areas
- Necessary to maintain acid-base
balance and electrolyte balance
Needed for many enzyme reactions,
transmission of nerve impulses,
contraction of cardiac/skeletal/smooth
muscle, gastric function,
renal function, tissue synthesis, and
carbohydrate
metabolism.
An imbalance causes problems in all
of these functions
N4810 Clinical Paperwork Rev 11-6-2013

Chloride

98-107

103

105

105

Glucose

70-110

128 (H)

191 (H)

Calcium

8.8-10.2

8.5

174 (H)
@1200
FSBS 202.
4 untis
medium
dose Lispro
given. (Left
abdomen,
subcut)
9.8

Magnesium

1.7-2.4

Kidney
Function:

-Elevation can hint to problems such

as an infection
Insulin
-To assess for malnourishment
administered (increased risk of hepatotoxicity with
by nurse.
acetaminophen)

9.8

2.0
7

12

19

0.7

0.7

0.8

BUN

Creatinine

- Necessary to maintain acid-base

balance and electrolyte balance
Needed for many enzyme reactions,
transmission of nerve impulses,
contraction of cardiac/skeletal/smooth
muscle, gastric function,
renal function, tissue synthesis, and
carbohydrate
metabolism.
An imbalance causes problems in all
of these functions

Calcium helps balance Magnesium,

Phosphorous, and Potassium in the
blood, may reduce BP
Magnesium can help protect against
high BP, low Magnesium can increase
risk of osteoporosis
Kidney function tests are necessary to
check for toxic effects of the
antibiotics such as Vancomycin on the
kidneys. Also, to detect for kidney
damage related to problems with
perfusion of organs. We need good
kidney function to excrete drugs
risk of toxicity with excess levels in
body
Kidney function tests are necessary to
check for toxic effects of the
antibiotics such as Vancomycin on the
kidneys. Also, to detect for kidney
N4810 Clinical Paperwork Rev 11-6-2013

GFR

157 or
151?

Liver function:
AST

39

ALT

33

Bilirubin

0.6

Albumin

3.2 (L)

Name of test
pCO2

Normal
35-45

PO2

80-100

pCO3

22-26

damage related to problems with

perfusion of organs. We need good
kidney function to excrete drugs
risk of toxicity with excess levels in
body
157
135
Kidney function tests are necessary to
check for toxic effects of the
antibiotics such as Vancomycin on the
kidneys. Also, to detect for kidney
damage related to problems with
perfusion of organs. We need good
kidney function to excrete drugs
risk of toxicity with excess levels in
body
24
17
AST is an enzyme that helps
metabolize amino acids. High levels
can indicate liver damage or disease.
25
19
It is an enzyme that digests protein.
High levels indicate liver damage.
0.4
0.4
Bilirubin is a product of the
breakdown of red blood cells.
Elevated levels (Jaundice) liver
damage or disease
3.0 (L)
3.2 (L)
It is protein created in the lover. Low
albumin levels mean liver damage or
disease. The body requires albumin to
fight infections and to perform other
body functions as well.
Result 1 (latest)
Result 2
Rationale
41.9
42.8
Carbon dioxide of
arterial blood/increases
to balance an alkaline
state/ this is like the acid
of blood
146 (H)
228 (H)
Oxygenation of Arterial
blood
22.9
26.7 (H)
Bicarbonate in blood
(increases in an acid
state/ this is the base of
N4810 Clinical Paperwork Rev 11-6-2013

pH

DIAGNOSTIC DATA
ECG
CT

7.35-7.45

7.37

7.41

blood)
Acid base balance

Student Name: _Bobbie Chahal

Normal Sinus Rhythm
Submandibular edema. No fluid collection/no
evidence of abscess. Soft tissue thickening at
oralpharynx trauma from E.T. and OG tube
placement. Suture intact. No masses, no
lymphadenopathy.
Marked interval partial resolution of a
consolidation infiltrate in Left Mid Lung.
Pulmonary vascular congestion bilaterally.

N4810 Clinical Paperwork Rev 11-6-2013

N4810 Clinical Paperwork Rev 11-6-2013

Concept Mapping

Student Name: Bobbie Chahal_

1.Nursing Diagnosis: Ineffective breathing pattern r/t airway obstruction caused by dental abscess
Data to support: O2 Sat: 100% pCO2: 42.8 pO2: 228 (High)
pCO3: 26.7 (High) pH: 7.41 (Normal)
*All of these ABG values obtained while on Ventilator setting: Assist Control PEEP 5, Respiration Rate Set: 20, Tidal VolumeMechanical (500), FiO2: 100%)
Medications: SOLUMEDROL (decrease inflammation), Albuterol PRN (bronchodilator)
Assessment findings: He is breathing in synchronization with the ventilator. There is still palpable inflammation present in the pharynx
region that will impair breathing when the patient is extubated. Antibiotics and Methylprednisolone are important right now so that
way the dental infection and inflammation can resolve so the patient can have a patent airway. Because of the inflammation, the
patient is on a ventilator and needs breathing support. Lung sounds are diminished with no adventitious sounds heard. There is a
presence of consolidation related to pneumonia in the lungs.
Interventions:
Monitor O2 saturation, breath/lung sounds & respiration rate (monitor the breaths taken independently by the patient in addition to the
mandatory ventilated breaths)
Suction to keep airway clear
Maintain and protect endotracheal tube
Prevent ventilator acquired pneumonia (oral care, HOB 30 degrees, administer PEPCID)
Ventilator settings adjusted to meet oxygenation needs
Sedation Vacation to check if ready to wean off of ventilator.
Albuterol treatments PRN (RT did not do any while I was there)
2.Nursing Diagnosis Impaired gas exchange r/t ventilation imbalance caused by pneumonia
Data to support: X-ray lung findings: Left Middle Lung Lobe consolidation
RBC 3.66 (L) Hemoglobin 11.2(L) Hematocrit 32.6 (L)
O2 Sat: 100% pCO2: 42.8 pO2: 228 (High)
pCO3: 26.7 (High) pH: 7.41 (Normal)
*All of these ABG values obtained while on Ventilator setting: Assist Control PEEP 5, Respiration Rate Set: 20, Tidal VolumeMecahnical (500), FiO2: 100%)
Medications: Albuterol and Solumedrol to keep airways open. Levofloxacin (LEVAQUIN), Vancomycin (VANCOCIN), Piperacillintazobactam (ZOSYN) administered to fight pneumonia/dental infection
Assessment findings: Respiratory rate of 20, no retractions, Diminished lung sounds with no adventitious sounds. This can indicate
poor inspiratory effort, yet no presence of fluid in the lungs.

N4810 Clinical Paperwork Rev 11-6-2013

Interventions: Assessed respiration quality and rate.

Assessed lung sounds and checked for presence of adventitious sounds.
Vital signs and ABGs monitored.
Skin color noted and respiratory secretion quality noted (serosanguineous)
HOB elevated to help with lung expansion and air exchange
Patient re-positioned every 2 hours to help with movement and drainage
Suctioned PRN and oral care provided
Anti-inflammatory given to decrease inflammation of airway
Anti-infectives administered for pneumonia and dental infection

3.Nursing Diagnosis: Risk for sepsis r/t release of bacteria/pathogen into the bloodstream.
Data to Support:
Increased WBC level (13.5)
Increased temperature (102 F) Temperature fluctuated throughout both days. Tylenol suppositories did help decrease it.
Medications: Zosyn, Vancomycin, Levaquin (all of these are anti-infectives/anti-biotics), Tylenol (for fever)
Interventions:
Administer antibiotics ordered!
Assess for and report signs and symptoms of sepsis (fever, diaphoresis, tachypnic breathing rate, tachycardia, increase in WBC, blood
culture positive for pathogen)
Use sterile technique during invasive procedures (IV insertions)
Pay attention to nutritional status
Low stimuli environment (dim lights, limit visitors, calm attitude, manage sedation/analgesia, explain rationale for interventions)
Change tubing in a timely manner based on policy and also when soiled or compromised.
Suspect sepsis?
Report to physician and follow sepsis protocols! (oxygenation, blood culture, antibiotics, fluids, vasopressors, monitor vital signs,
monitor urine output)
4.Nursing Diagnosis: Risk for skin breakdown r/t dehydration, restraints, and antecubital IV infiltration
Data to support: Patients skin was intact with no redness, no breakdown at the coccyx and the rest of the body prominences. Patients
Right antecubital IV line was infiltrated and so arm was swelling. Other than that, no skin issues from restraints.
Medications: Moisturizing lotion applied around bony prominences and perianal care given prior to changing from an indwelling foley
catheter to a condom catheter.
Assessment findings: Skin swelled at the right antecubital arm region due to IV line infiltration. The skin on body did not have any

N4810 Clinical Paperwork Rev 11-6-2013

lesions or breakdown otherwise. Brisk turgor. Warm, dry skin.

Interventions: Infiltrated line infusion stopped. Used a different IV site. Repositioned every two hours and skin assessed during the
turning process. Provided cushion with pillows at the bony prominences. Peri-anal care provided. Legs elevated and SCDs applied on
both legs.
Restraint checked for tightness every thirty minutes. Restraint taken off every 2 hrs for 15 minutes and skin assessed.
5.Nursing Diagnosis: Nutrition: Less than body requirements
Data to support: Hypoactive bowel sounds that progressed to absent bowel sounds on the second day. 3rd day patient was NPO.
Orogastric tube clamped/no feedings.
Medication: No feedings. On Potassium replacement scale.
Interventions: The patient did not receive any type of feeding so far because there was uncertainty about whether he needed additional
surgery to fix the problem in the neck from the inside. This statement by the family caused confusion with the healthcare team
because the patients said , The doctor told us that they fixed the problem from the outside but they still have to go in and fix the
problem on the inside. So there was confusion about the need for further surgery. When discussed with oral surgeon, he reported that
there were no complications that required further surgery and that the inflammation related to the dental infection was the only thing
preventing the prompt extubation of the patient.

N4810 Clinical Paperwork Rev 11-6-2013

Student Name: _Bobbie Chahal__

Problem Evaluation
Problem #
1

Evaluation of Patient Response

Respiratory rate of 20, no retractions, breathing synchronized with ventilator.
Diminished lung sounds with no adventitious sounds. O2 saturation remains at
100%. ABGs normal. Skin is warm, no cyanosis or pallor, nail beds pink, Airway
kept patent., Vancomycin and Levaquin still ongoing. No further respiratory
complications present other than inflammation from dental infection. Clear,
diminished lung sounds. No adventitious sounds.
Respiratory rate of 20, no retractions, breathing synchronized with ventilator.
Diminished lung sounds with no adventitious sounds. O2 saturation remains at
100%. ABGs normal. Skin is warm, no cyanosis or pallor, nail beds pink, Airway
kept patent., Vancomycin and Levaquin still ongoing. No further respiratory
complications present other than inflammation from dental infection. Clear,
diminished lung sounds. No adventitious sounds.
His WBC reached level of (13.5/HIGH) but his fever was brought down with
Tylenol suppository to 100.2 F. Suctioning resulted in scant serosanguineous
secretion possibly related to patient getting up at the end of noc shift and a stitch
at the neck become undone (re-sutured by E.D. doctor). He did not exhibit further
signs of complications from the infection. RR and BP remained stable. Was not
diaphoretic and was having a urine output of at least 100 mL/hr. He was finishing
antibiotic therapy and was receiving anti-inflammation medication to resolve
airway obstruction issues so that he could be extubated.
Other than the swelling on the Right antecubital region of the arm related to IV
infiltration, there were no skin complications. No redness or breakdown at coccyx
and other bony prominences. Brisk skin turgor. Barrier cream applied. Warm, dry.
Arms where the restraints are applied do not present any skin breakdown.
The statement by the family caused confusion with the healthcare team because
the patients family said, The doctor told us that they fixed the problem from the
outside but they still have to go in and fix the problem on the inside. So there
was confusion about the need for further surgery. When discussed with oral
surgeon, he reported that there were no complications that required further surgery
and that the inflammation related to the dental infection was the only thing
preventing the prompt extubation of the patient. Hopefully, the inflammation

N4810 Clinical Paperwork Rev 11-6-2013

decreased and the patient was extubated.

N4810 Clinical Paperwork Rev 11-6-2013

Student Clinical Self-Appraisal

Weekly (turn in with Care Plan/Map)
Student __Bobbie Chahal______ Course N4810_____ Instructor __Chris Johns
Instructions: Please evaluate your performance during clinical today using the following
concepts:
Client Advocate
Professional Demeanor
Flexible
Critical Thinking
Communication/rapport
Coordinator of Care
Self-Initiated
Technical skills
Team Player
Professional Accountability Organized
Educator
Leadership
Well-prepared
Ability to Prioritize
Nursing Process
Comprehensive Assessment
Knowledgeable
Areas of Strength Today (Date)

Areas Needing Growth-Include plan of

improvement
Self-Initiated/Leadership: I initiated looking up drug Knowledgeable: I need to continue studying
compatibility myself. I also kept track of which
ventilator settings.
medications were due when and kept track of
Technical skills: This clinical, I administered
planned interventions and what questions we had
Propofol. Starting an infusion that uses a vial
for the Dr.
instead of the normal bags was a new experience
for me. Also, I found myself being really cautious
with so many infusions going on so I would
Ability to Prioritize: I was able to prioritize between double check the lines and where each infusion
tasks such as keeping an eye on my patient during
was going before hanging up another infusion. I
times when he would begin to wake up and sit up
also did not feel comfortable just relying on my
rather than continuing charting and not making sure nurse to figure out if medications were
he didnt pull out any tubes.
compatible. So I double checked compatibility
even if I had checked compatibility on the prior
infusion of the same medication. This
Communication/rapport: The nurse began to trust
skill/confidence will come with experience.
me enough to add volume to the pump when the
infusion was near completion. I was really happy
she let me do this because I have always been
Critical thinking: During the clinical, I made the
reluctant to mess with the pumps. I would of course, effort to find out the chain of problems that lead
tell her how many remaining mL to be infused the
my patient to end up needing an artificial airway. I
pump was indicating versus how many we can add
think I should just keep on striving to be assertive
in.
and keeping in mind that clinical is meant to be
taken advantage of in asking questions and really
Well-prepared: Knowledgeable: I was
studying the patients chain of problems and the
knowledgeable about the medications administered. rationale to the treatment.

N4810 Clinical Paperwork Rev 11-6-2013

Instructor Comments:

N4810 Clinical Paperwork Rev 11-6-2013

Students Name: Bobbie Chahal

Pts Initials: Not my patient

Date:11/7/14

1ST white arrow (beginning of P-wave)

2nd white arrow (ending of T-wave)
Atrial rhythm: Regular

Ventricular rhythm: Regular

Atrial Rate 15 boxes/1500100 bpm Ventricular rate 16 boxes/1500 93.75 94 bpm

PR interval 4 boxes/ 0.16 sec (normal:0.12 to 0.20 seconds (3 to 5 small boxes)
QRS interval 2 boxes/0.08 sec (normal: 0.06 to 0.12 seconds (1.5 to 3 boxes)
QT interval 11 boxes/ 0.44 sec (normal: 0.36 to 0.44 seconds (9-11 boxes)
Is AV conduction normal? (Y/N)______________ If not, why is it abnormal?
________________________________________________________________________
P wave normal? (Y/N)

QRS complex normal? (Y/N)

Are all of the QRS complexes the same? (Y/N) ___________________

Are there premature beats? (Y/N)
Interpretation of rhythm:
Normal sinus rhythm with a heart rate of 100 bpm.
Potential hemodynamic consequences of this rhythm and interventions for this rhythm:
This is a normal sinus rhythm. Since there are no abnormalities/consequences of the normal
sinus rhythm and the patient has no cardiac issues, there is no treatment needed.

N4810 Clinical Paperwork Rev 11-6-2013

Student Name: ___Bobbie Chahal___________ Date: 11/7/14

Clinical Instructor: Chris Johns

Instructions: Attach a copy of this form to the back of each of you Clinical Plan of Care/Maps for grading purposes.
Grading Rubric:
1.
Patient Data includes:
a. Health history
b. All blanks and/or issues are addressed

20 points possible _____

2.

Each medication includes:

a. Name
b. Rationale
c. Side effects
d. Nursing implications-specific to this patient

20 points possible _____

3.

Lab Diagnostics
a. Test
b. Results
c. Implications & Teaching

10 points possible _____

4.

Problem Identification includes

20 points possible _____
a. Correctly lists individualized needs
b. Correctly identifies problems
c. Problems are prioritized and numbered, each problem in priority of importance
d. Map includes at least five physiological problems, discharge planning and patient education
e. Each problem includes:
i. Nursing diagnosis
ii. Data to support
iii. Medication
iv. Nursing treatment (interventions)

5.

Planned interventions includes

a. Interventions appropriate
b. Correctly prioritizes interventions
c. Assessments performed
d. Communication
e. Patient teaching
f. Discharge planning

10 points possible _____

6.

Evaluation of Interventions includes

a. Evaluates physical interventions
b. Evaluates teaching

10 points possible _____

7.

a.

Priority Assessments are appropriate to diagnoses

b.

Clinical Paperwork is complete

Total Points

10 points possible ____

_____________/100 = ____%