FAYETTEVILLE TECHNICAL COMMUNITY COLLEGE

ASSOCIATE DEGREE NURSING PROGRAM

NUR-114 CLINICAL PAPERWORK

Commented [F1]: Satisfactory. Well Done.

Student Name: ______ ________________ Date: _______________04-02-15______________

General Patient Information
Patients Initials: ____TW___ Room #:____31_Age: ___38_ Sex: _F___ Date of Admission: _04-01-2015_______
Height: ____not assessed____

Weight: ______45kg______

Commented [F2]: This can be found in the MAR or on the

Admission Assessment.

Allergies (explain type of reaction experienced):____NKDA______________________________________

Admitting Diagnosis: ___Pulmonary sarcoidosis____________________________________
Pertinent Health History/Surgeries: _pt unable to verbalize due to bipap______________________________________
__________________________________________________________________________________________________

Commented [F3]: condition is a better word because people

can still talk with bipap on. Since she was a new admission you can
also but unable to obtain due to patient condition and family not at
bedside. New admit from ED and no history present in chart

Code Status: ____full________ Isolation Precautions: ___________standard__________________________

Health Patterns Assessment (complete the following information)
Stated reason for hospitalization: unable to verbalize(admitted to ED with complaint of cough, congestion, sore throat)
What other health problems have you had? ____pt unable to verbalize_due to BiPAP
__________________________________________________________________________________________________
Significant family medical history (Heart disease, cancer, diabetes) __pt unable to verbalize due to BiPAP_________
__________________________________________________________________________________________________
Medications taken at home (include OTC and herbal supplements) ___atorvastatin, cyproheptadine, fluticasonsalmeterol, folic acid, furosemide, lisinipril, metFORMIN, potassium chloride,___________________________
Do you take your medications as prescribed? ____pt unable to verbalize due to BiPAP__
Tobacco use (type and frequency) _unable to assess_________ ETOH use (type and frequency) unable to assess_____
Non Prescribed Drug use (type and frequency) _____unable to assess____________
Exercise (type and frequency) ___unable to assess___________________

Home Diet (number of meals per day, general description of diet) ___pt unable to verbalize due to BiPAP_____
__________________________________________________________________________________________________
(Reviewed January 8, 2015)

Commented [F4]: Always put why you are unable to assess. EX

due to condition.

Physical Assessment Findings:

Patients general appearance (well-groomed, poor hygiene, etc):__pt hygiene poor
Behavior: __pt is agitated and refuses placement of NG tube__
Vital Signs: BP___118/72___ HR__83______ RR___BiPAP______________ O2 Sat__85% (lowest noted)__
Temp (specify oral, tympanic, axillary, rectal) __not assessed________________
Pain rating (identify scale used) _pt denies______ Location ________n/a________________

Commented [F5]: Remind me to show you how to see

respirations on bipap. You can also count respirations on bipap. This
would not be acceptable charting in the hospital.
Commented [F6]: You can also put pt on "100%" bipap to show
that it is being addressed. If you have an abnormal value always put
what you are or what you did for that abnormality and the
response.

Onset __n/a__________Frequency ____n/a_____Duration ___n/a______Radiation___n/a______

Precipitating factors__n/a_________ Method of relief _____n/a____
Neurological:
Orientation___pt A & O +2 (name & place)
Pupils/PERRLA__left eye is milky & pupil not visible __Size (mm) ____not assessed_______

Commented [F7]: What about the right pupil. This is an

important neuro assessment

Extremity Strength (equal bilaterally?)____not assessed___________

Speech__pt unable to speak with BiPAP but can nod/shake head in response to questions________

Commented [F8]: This is a great phrase to use.

Gag Reflex ___on BiPAP_____________ Ability to swallow___on BiPAP _______________

Commented [F9]: "Unable to assess, pt on continuous bipap

Eyes, Ears, Nose, Throat:

Sclera appearance, eye drainage, vision impairment, glasses/contacts, etc_sclera white, no drainage noted____
Ear drainage, hearing impairment, hearing devices, etc ___no drainage, impairments, or devices noted__
Nasal drainage, nares patent, etc___Unable to assess due to BiPAP___________
Throat appearance__Unable to assess due to BiPAP______
Teeth (cavities, missing teeth, dentures, etc) __unable to assess due o BiPAP_____
Cardiovascular:
Heart sounds_____S1 S2 noted______________
Rhythm (regular/irregular) ___regular__________________
Quality of pulse (bounding, strong, normal, weak, absent, Doppler) ____normal____
Capillary refill ___not assessed_____________________
Cyanosis___none noted __________ Bleeding precautions____no_________________________
Edema (location, pitting/non-pitting, grade) ___none noted_______________
Telemetry:

yes/x

no Identified cardiac rhythm___not assessed_________________________

Commented [F10]: This should be assess with every

assessment. With the low oxygen this would probably be >3
seconds

Pacemaker__no______ Complaints of chest pain? ___pt denies___________________________________

IV access (include location, site appearance, date of insertion) saline lock inserted in right forearm on 04/01/15 no s/s of
inflammation noted, saline lock inserted 04/02/15 to left forearm on 04/02/15 no s/s of inflammation noted

Commented [F11]: and redness

IV infusion (type of solution, rate of infusion) __saline locked__

Respiratory:
Pattern__BiPAP________ Depth __BiPAP____________ Effort

BiPAP___________________

Lung sounds
Anterior: Right___wheezing_________________ Left______wheezing__________________
Posterior: Right ____wheezing__________________ Left ___wheezing___________________
Cough ___none noted___________ Productive_____n/a_____________________
Secretions (amount, color) __none noted__________________________
Supplemental O2__BiPAP_ Complaints of shortness of breath? _____yes____
Trach___no______________________
Gastrointestinal:
Bowel sounds: RUQ_didnt assess__ RLQ___didnt assess LUQ_didnt assess_ LLQ _didnt assess_
Abdomen (flat, round, obese, soft, distended, firm, etc.) __distended______________
Tenderness

no

Location ______n/a___________________________________________

Last bowel movement___04/02/15______ Character, consistency__loose__________________________

Nausea___not assessed___________________ Vomiting ____no__________________
NG/OG/Dobhoff/Peg ___OG placed on 04/02/15__ Placement confirmed___order for xray___ Residuals no____
Ostomy (type, location, stoma appearance) _____none_______________________________________

Commented [F12]: Put how it was confirmed. This statement is

vague. I would like more information. EX: NGT placed in right nare
to 65 cm. Aspirated gastric content green with sediment. Air
auscultation also confirmed. Chest xray ordered and waiting on
results. Clamped until xray confirmed placement.

Hospital diet (include supplements and rationale, and route if applicable) OG tube placed on 04/02/15 dietician will
consult____________________________________________________________________________________________
Genitourinary:
Last void____voids_________ Appearance _____n/a___________________________________
Bladder (distended/ non-distended) _________________________ Incontinence__voids______________________
Catheter type and size ___none/voids ______________________ Date inserted ____n/a__________________________
Penile/vaginal discharge_____none noted_________ Ostomy: no Type/location__n/a____________
Dialysis:

no

Type: hemodialysis peritoneal dialysis

Commented [F13]: This should be a date and time

Hemodialysis access:

AV graft

AV fistula

Dialysis Catheter

Tenckhoff

Location____n/a________

Appearance ___n/a__________________________________ Date of dressing change____n/a______

Bruit ____n/a_________________ Thrill ______n/a__________________________
Integumentary:
Characteristics (color, temp, condition) __warm, dry, brown_____________________
Turgor ___good_________________
General description of skin___intact__________
Wounds/Drains/Dressings (include location, appearance, and type)_ none noted_________________________
__________________________________________________________________________________________________
Musculoskeletal:
Range of Motion (full, contracted, and/or limited):
RUE______full______________________ RLE____full___________________________
LUE_______full_______________________ LLE_______full________________________
Muscle tone (normal, decreased, increased, flaccid, atrophy, rigid, spastic)
RUE____normal__________________________ RLE___normal____________________________
LUE_________normal____________________ LLE_____normal_________________________
Amputations

no

Ortho equipment

Describe_____________n/a____________________________________________
no

Describe___n/a______________________________

Gait (steady, unsteady, needs assistance, etc.) __not assessed/on BiPAP_________________

Discharge Planning (describe the needs of the patient during discharge planning):
Pt will need to follow up with primary physician. Pt will need respiratory therapy/physical therapy consult.

Health Teaching (describe at least 2 teaching needs of the patient):

Pt needs medication education and education on seeking medical attention when experiencing worsening pulmonary
symptoms

FAYETTEVILLE TECHNICAL COMMUNITY COLLEGE

ASSOCIATE DEGREE NURSING PROGRAM
NUR-114 Laboratory and Diagnostic Tests Data Sheet

Commented [F14]: There is so much teaching and discharge

planning that will need to be done for her. With her being a new
admission it is hard to pick the best one. These are good.

Lab Values

Clients Value
(Normal, High, Low, Critical)

Describe the significance of the abnormal lab for

this patient

HEMATOLOGY
WBC
7.3
5.43 high

RBC

Chronic state of hypoxia causes stimulation of RBC

production as a physiologic response to increase
oxygen carrying capacity

Commented [F15]: Great!

HGB
14.4
46.1

HCT
COAGULATION
Platelets

263
PTT
PT/INR
CHEMISTRY
Glucose

Acute stress response or corticosteroid therapy

191 high

Sodium
136
Potassium
3.9
Chloride
101
Calcium
8.3 low
BUN

Granulomatous infections such as sarcoidosis

increase vitamin D level, which in turn increases
PTH to release Calcium
Possible rhabdomyolysis (side effect of Lipitor)

25 high
Creatinine
1.2
Total Protein
6.8
Albumin

Malnutrition/inflammatory response
2.9 low

URINALYSIS
Color
Specific Gravity

Ketones
Protein
OTHER LABS

Clients value
(normal, high, low, critical)

Describe the significance of the abnormal lab for

this client

Commented [F16]: Possible dehydration

pH Art

7.12 LOW

Respiratory Acidosis

pCO2 Art

81.2 HIGH

Increased pCO2 from reduced ventilation caused

by sarcoidosis

pO2

96.9

HCO3 Art

25.6

ctHb Art

16.5

COHb Art

1.9 high

Hypoxia

O2Hb Art

92.6 low

hypoxia

MetHv Art

0.6

HHb Art

4.9

HCT Art

49

Diagnostic Tests (other than labs)-Radiographic studies, ECG, Endoscopy, etc.

Date
Name of Test
Results
Implications
04/02/15 CT scan of
Extensive fibrotic changes are seen
Lungs are worse than previous scan. In
chest w/out
throughout the lung parenchyma more
addition to increased nodules, there is also
IV contrast
predominately within bilateral upper
a pleural effusion. This in combination
lobes with scattered areas of nodularity
with sarcoidosis is causing a decrease in
seen most consistent with pulmonary
lung function. Pt cannot properly ventilate
sarcoidosis. Findings have progressed
the lungs which is increasing CO2 in her
since prior exam in 2009. There is a small body and causing acidosis.
right pleural effusion seen. Heart and
pericardium appear normal. There is
some perihepatic ascites seen with some
edematous changes in the visualized
memory.

04/01/15 Chest XRAY

2 View
Frontal &
Lateral

Frontal and lateral views of the chest

were obtained and compared to 10/14/14
demonstrating pulmonary hyperinflation
consistent with COPD. There is a
infiltrative process in the left lung field, I
believe, posteriorly which may reflect a
pneumonia. The heart, mediastinal and
hilar structures are stable in appearance.
There are stable fibrotic changes in the
right lung apex.

Lungs are hyperinflated which means pt

cannot take depth breaths and cannot
ventilate CO2. If pt patient has
pneumonia, oxygenation is further
compromised.

DATE
TIME
ALL NOTES MUST BE SIGNED AND DATED
04/02/15 0500 38yr old black female admitted to ED with complaints of cough, congestion, and sore throat. Hx
of sarcoidosis. Chest XRAY & CT Scan confirm worsening of sarcoidosis, with pleural effusion,
and possible PNE. ARB is 7.26. Transferred to 8 South to begin BiPAP and continous monitoring.
0700

0745

Pt A & O+2 (name & situation). VS: 118/72, HR 83, 85% SpO2. Pt denies pain. Abd distention
noted, but pt still refuses NG tube placement. Wheezing noted in all lung fields. S1S2 noted with
regular rate & rhythm. Skin in warm, dry, and intact. Tugor is good. No cyanosis noted. Sclera is
white, but left eye is milky. No edema note. Saline lock on rt forearm no s/s of inflammation. Pt
is sitting in bed leaning forward. Will continue to monitor. Left pt with side rail up x 2 and call
bell within reach. Rapid response is on floor & crash cart outside of pt room.----------------------------------

Commented [F17]: Pt reoriented to time and place. Always

follow up with what you do for abnormal, even with this.

Latest ABG reveals worsening acidosis (7.19 ph, 68.3 pCO2) Pt still alert but with increased
periods of rest. HPC notified by rapid response. No order for intubation at this time. Will
continue to monitor & wait for next ABG. ----------------------------------------------------------------------------------------

Commented [F20]: or see ABG results

1000

Latest ABG 7.12pH, 81.2 pCO2. SpO2 has not improved. HPC ordered intubation. Pt had loose
bowel movement. No breakdown noted to sacral area. Rapid response on floor and ready to
begin intubation.---------------------------------------------------------------------------------------------------------------------

1030

Pt intubated. OG tube placed and IV placed in left forearm by RT/rapid Response team. Pt
tolerated well and has been moved off floor to unit. -----------------------------Amy H Cooper, SN,
FTCC

Printed Name:Amy H Cooper

Signature/Title:Amy H Cooper, SN, FTCC

Fayetteville Technical Community College

Commented [F18]: What is good?

Commented [F19]: Go head to toe on your assessment and this

could help you keep on track and not miss information

Commented [F21]: I might have mentioned in my first note

that rapid response was called during the night and still at bedside
this am. They continue to monitor patient and doctor throughout
the morning.

Commented [F22]: Sign ALL notes. These are good notes

because they get down to the point and are not overbearing with
information. They just need some organization. Well done.

ASSOCIATE DEGREE NURSING PROGRAM

NUR-114 Clinical Pathophysiology
Primary Medical/Surgical Diagnosis___Pulmonary Sarcoidosis_________________________
Etiology and Risk
Clinical
Diagnostic Findings
Medical/Surgical
Factors
Manifestations
Management
Sarcoidosis is a
Sarcoidosis is
Sarcoidosis is staged The focus of therapy
granulomatous
suspected in the
on the basis of x-ray is to lessen
disorder of unknown patient who has a
findings. Higher
symptoms and
cause that can affect cough, dyspnea, and stages have greater
prevent fibrosis.
any organ, but the
abnormal chest x-ray damage and
Management varies.
lung is involved most but is otherwise
widespread disease. If the patient is
often. It develops
asymptomatic.
Pulmonary function
asymptomatic and
over time with
Other conditions to
studies often show a has normal
growths called
rule out before
restrictive pattern of pulmonary function,
granulomas forming diagnosing
decreased lung
no treatment is
in the lungs.
sarcoidosis are lung
volumes and
given. Decreased
Granulomas contain infections and
impaired diffusing
total lung capacity
lymphocytes,
cancer.
capacity. Irreversible (TLC), diffusing
macrophages,
Bronchoscopy with
lung changes occur
capacity, or forced
epithelioid cells, and biopsy may be used
in 10% to 15% of
vital capacity (FVC);
giant cells. The
in the diagnosis of
patients. Patients
involvement of other
disease affects
this disorder
who have severe
organs; and
young adults.
restrictive disease
hypercalcemia are
Manifestations
may develop
indicators for
include enlarged
secondary
treatment.
lymph nodes in the
pulmonary
hilar area of the
hypertension.
Corticosteroids are
lungs, lung infiltrate
the main type of
on chest x-ray, skin
therapy. Dosages
lesions, and eye
vary from 40 to
lesions. The first
60 mg daily with
indication of disease
tapering doses over
may be an abnormal
6 to 8 weeks, to a
chest x-ray in an
maintenance dose of
otherwise healthy
10 to 15 mg daily for
patient. The most
6 months. Further
common symptoms
therapy may
include cough,
continue over 12
dyspnea,
months. Drugs under
hemoptysis, and
study for
chest discomfort. In
management of this
many patients, the
disease include
illness resolves
thalidomide
permanently. Others
(Thalomid) and
may have
infliximab
progressive
(Remicade) (LaRue,
pulmonary fibrosis
2009). Follow-up and
and severe systemic
monitoring include
disease.
assessment of
symptom severity,
pulmonary function
studies, chest x-rays,

Nursing Care
Pt education of
medications and
importance of
adherence. Pt
education on follow
appointments.
During periods of
acute exacerbations
current monitoring
of SpO2,
respirations, and all
other VS. Patient
may need
supplemental O2 or
pressurized O2
therapy. Constant
monitoring of blood
gas, chemistry, and
blood panel.
Maintaining SpO2 of
90% is a nursing
priority.

a complete blood
count, serum
creatinine, serum
calcium, and
urinalysis. Teach the
patient about side
effects of steroid
therapy and other
aspects of physical
care as indicated.

Secondary Diagnosis and brief description:

__________________________________________________________________________________________________
_Pulmonary effusion is air in the pleural space. If a pleural effusion is present, fremitus may be decreased or absent
on palpation, percussion may sound flat, and breath sounds are decreased on auscultation. With compression of lung
tissue near the effusion, abnormal breath sounds include bronchial breath sounds, egophony, and whispered
pectoriloquy.

Medication Worksheet
Drug Name

Classification

Mechanis
m of
Action

Dose,
Route,
Freque
ncy

Rationale
for taking
drug

Anticoagulant/throm
bolytic

Inhibits
Vitamin K
dependent
coagulation
factor
synthesis
Inhibits the
synthesis of
cholesterol.

2 mg po
daily

Atrial
Fibrillation

Hemorrhage: reverse with

administration of Vit K

Monitor
PT/INE, Plt

20mg PO
QHS for
30 days

To lower
cholesterol
/LDL levels

Rhabdomyolysis, liver enzymes

Monitor liver
enzymes,
renal
function,

(trade/generic)

Ex:
Warfarin/Cou
madin

Lipid lowering
atorvastatin/Li
pitor

Adverse side effects

Nursing
considerati
ons

muscle
cramps

Cyproheptadin
e HCL
periactan

Fluticasonesalmeterol/
Advair Diskus

Potassium
chloride

lisinopril

allergy, cold and

cough remedies
antihistamines

Relief of
allergic
symptoms
caused by
histamine
release

4mg PO
TAB
QDAY for
30 days

Allergies

Drowsiness, dry mouth, blurred vision

Monitor lung
functiom
(may thicken
secretions,
monitor
weight

Corticosteroid/
bronchdialtor

Antiinflammator
y/ dialates
bronchi

250 mcg50mcg
blister
with
device 1
puff by
inhalatio
n

To improve
lung
function by
reducing
inflammati
on inside
bronchi/
dilates
bronchi to
improve
lung
function

ANAPHYLAXIS , LARYNGEAL
EDEMA ,URTICARIA, AND BRONCHOSPA
SM, CHURG-STRAUSS SYNDROME,
fever

Monitor for
signs and
symptoms of
hypersensitivit
y reactions
(rash, pruritis,
swelling of
face and neck,
dyspnea)
periodically
during
therapy.
Monitor
lungs, BP,
HR, and
serum K+
Monitor
serum K+
levels, s/s
hypokalemia
&
hyperkalemi
a

ASTHMA-RELATED DEATH, paradoxical

bronchospasm, cough

Mineral/electrolyte
replacement

Maintain
acid-base
balance,
isotonicity,
and
electrophysio
logic balance
of the cell

20mEq, 1
tablet PO
daily

Salmetrol
can
decrease
serum K+
levels so
supplement
is needed

ARRHYTHMIAS, ECG changes

Anti hypertensive

ACE
inhibitor

2.5mg PO
once a
day

To control
HTN

ANGIOEDEMA, hypotension
Assess
patient for
signs of
angioedem
a
(dyspnea,
facial
swelling).
Monitor
weight and
assess patient
routinely for
resolution of
fluid overload

NURSING
DIAGNOSIS
(List 1: NDX, R/T,
AEB)

PATIENT GOAL
(List 1: action verb
the patient
will)

NURSING
INTERVENTIONS
(List 4: action verbs
the nurse will)

(AEB should be in
your assessment
write-up)

(Speak to R/T to
improve AEB)

(speaks to R/T and Goal

to improve the NDX)

Impaired gas
exchange R/T
ventilation
perfusion
imbalance AEB
dyspnea, ABG 7.12,
pCO2 81.22, 85%
SpO2, Ca 8.3, 5.43
RBC, abnormal
chest XRAY, and
abnormal CT scan

DOCUMENTED
RATIONALE
(To prevent, increase,
decrease,
promotelist text
and pg #)
(Rationale of
intervention)

Pt will maintain
SpO2 level of
>90% & improve
ABG level by end
of shift.

1) Nurse will monitor

SpO2 continuously
using pulse oximetery.
2)Nurse will
auscultate lungs every
1-2 hours

3)Position pt with
head of bed at 30-45
degree angle

4) Monitor clients
behavior & mental
status

2) O2 of less than
90% indicates
significant O2
problems.
2)Crackles&
wheezing will alert
nurse to airway
obstruction

EVALUATION
(Evaluate all parts: is
the NDX still
pertinent? Was the
Goal met or not met?
Did the interventions
work or not? What
should be changed?)
Pt could not maintain
90% SpO2 level and
ABG became
progressively worse.
Pt had to be intubated
& moved to unit. Pt
probably should have
gone straight to unit
instead of floor.

Commented [F23]: Excellent diagnosis! Well done.

3) Decreases risk of
aspiration

4) Changes in
behavior & mental
status can be early
signs of impaired gas
exchange

Commented [F24]: This is very important to note patient

deterioration. Pt that suddenly change in mental status are in
serious trouble.

References
Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning
care (10th ed.). Maryland Heights, Missouri: Mosby Elsevier.
Ignatavicius, D. D., & Workman, M. L. (2013). Medical-surgical nursing: Patient-centered collaborative
care (7th ed.). St. Louis: Elsevier Saunders.
Pagana, K. D., & In Pagana, T. J. (2014). Mosby's manual of diagnostic and laboratory tests (15th ed.). St.
Louis.
Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2014). 2014 drug information update for Davis's drug guide
for nurses, thirteenth edition and Nurse's med deck, thirteenth edition (13th ed.). Philadelphia: F.A.
Davis Company.