Nursing Care of the Adult Client

Clinical Paperwork

Clinical Paperwork and Nursing Care Plan

Student
Name:

Danielle Reed

Patient
Initials: NM

Clinical
Date:
Admission
Date: 9/27/14

9/30/14
Room
#: 732

Gender:

Female

Race:

Mixed race- Kurdish

Marital
Status:

Married

Allergie
s:

NKA

Ag
e: 80

Code Status:

NA

Admitting
Diagnosis
(Reason for
admission;
presenting s/s):

Labile hypertension, SOB on exertion, malaise, fatigue,

positional epigastric pain, hyponatremia

Secondary
Diagnosis (after
study, reason for
hospitalization):

Pancytopenia, labile hypertension, Congestive heart failure

Event(s) leading to hospitalization and summary of present hospitalization

Patient began experiencing labile blood pressure. She takes clonidine at home for
hypertension. She was experiencing fatigue, pain in right leg, and numbness in both
feet.

Past Medical/Surgical History and Management (past health problems/ comorbidities and therapy)

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Chest pain, congestive heart failure, hypertension, appendectomy, UTI, bilateral

PEs, Arthritis, gout, anxiety, and pulmonary embolus

Significant physical assessment finding that relates to patient condition or

new nursing concerns (identify pertinent information per system i.e
Neuro, Cardiac, Respiratory, etc)
The patient was experiencing some weakness, and this could be due to poor
nutrition and illness. The patient sleeps a lot, but her son ensures that she
ambulates daily.

Discuss the pathophysiology of the patients primary medical diagnosis. Take into consideration all the
gathered data and your physical assessment results. Identify how the patient is similar to and differs from the
textbook presentation of the disease. List your reference.

Heart Failure, or congestive heart failure (CHF) is a physiologic state in which the
heart cannot pump enough blood to meet the metabolic needs of the body. Heart
failure results from changes in systolic or diastolic function of left ventricle. The
heart fails when, because of intrinsic disease or structural defects, it cannot handle
a normal blood volume or, in the absence of disease, cannot tolerate a sudden
expansion in blood volume. Heart failure is not a disease itself; instead, the term
refers to a clinical syndrome characterized by manifestations of volume overload,
inadequate tissue perfusion, and poor exercise tolerance. Whatever the cause,
pump failure results in hypo-perfusion of tissue, followed by pulmonary and
systemic venous congestion. Because heart failure causes vascular congestion, it is
often called congestive heart failure.
Gould Pathophysiology textbook

Surgical ProceduresList all present surgeries, dates, rationale, results

Bilateral knee surgery (1998)
Cholecystectomy

Nutritional status-- include diet orders, pt. compliance with dietary

regime, I & O, height, weight, BMI, nausea, vomiting, altered nutritional
balance or status. If applicable, list any significant nutritional labs (i.e.
total protein, albumin, pre-albumin, magnesium, phosphorus).
Regular diet, nausea and hyponatremia, dietary supplements (Ensure), Wt: 110 lbs,
Ht: 62in, BMI: 20.1

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Psychosocial/Sociocultural/Developmental/Spiritual Assessments:
Assessments: Needs to support the nursing diagnoses identifiedsubjective and objective
Should choose and report on at least one area in each of the fields
below:
Psychosocial/Intelle
ctual

Perception of health status,

behavioral and emotional
status, support systems, selfconcept, body image, mood,
long and short term memory,
attention span, communication
patterns, educational level,
problem solving, intellectual
performance, how does client
cope with stress?

Due to the patients language barrier and

cultural practices communication was
translated through her son.

Sociocultural

Financial status, Recreational

activities, primary language,
cultural heritage, community
resources, environmental risk
factors, social relationships,
family structure and support,
home environment

The patient is retired, and her family assists

with her care. Her son is her caregiver.

Developmental

Erickson Developmental stage,

effect of health status on
developmental stage, growth
and maturation, educational
level, occupation, ability to
complete ADLs

This patient is facing the crisis is Ego Integrity

vs. Despair. At this age a person looks back
and reflects on what they have accomplished
and are they satisfied with who they have
become. In spite of his health problems this
patient, is very active and doesnt let illness
stop him. I dont think her illness is hindering
his overall development.

Spiritual

Life experiences and events,

Beliefs and meaning, religious
experiences, rituals and
practices, fellowship, courage

This patient is religious, and follows a Muslim

faith.

Pertinent X-rays and Diagnostic Procedures-- list all tests, procedures, dates,
rationale, and abnormal results

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Bone Marrow Biopsy: 9/29 (awaiting results)

Chest x ray: 9/26 for dyspnea, chest pain
US venous duplex lower ext. bilateral: 9/26- for leg pain
CT Scan of chest, abdomen, and pelvis (9/27)
EKG (9/26) Sinus bradycardia with 1st degree AV block; left axis deviation; left
ventricular hypertrophy
NM lung scan ventilation/perfusion (9/26) for exertional dyspnea, chest pain

Pertinent Lab Values: List significant and/or abnormal lab results. Include normal
ranges/ trends, and rationale:
Test:

NA
(Sodium
)
K
(Potassi
um)
Hemoglo
bin
Hematoc
rit
Platelet

Admissi
on
Result:
9/26
126

Intermitt
ent
Result :
9/28
127

9.4
26.2

Day of
Care
Result:
9/30

Normal
Ranges:

High
or
Low?

136-147

Low

9.2

12-16

Low

26.2

35-47

Low

150-400

Low

145

WBC

2.8

2.6

4.3-10

Low

BUN

30

42

8-26

High

RBC

2.96

2.94

4-5.4

Low

70-110

High

<230

High

8.1-10.2

Low

6.3-8.3

Low

Glucose
d-dimer

129
357

Calcium
T.
Protein

7.8
6.1

180

Rationale
(How does
this relevant
to the pt):
Antihyperten
sives without
adequate
H2O intake

pancytopeni
a
pancytopeni
a
pancytopeni
a
Inadequate
nutrition
HTN
pancytopeni
a
pancytopeni
a
pancytopeni
a
Inadequate
nutrition
Inadequate
nutrition

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Albumin

3.4

3.8-5

Low

AST

54

22-46

High

Folate

>24

3-17

High

Transfer
rin
Chloride

219

250-380

Low

98-109

Low

Co2

22

24-29

Low

BNP
Lymph %

517
12%

0-100
20-40

High
Low

Mono %

13

3-7

High

Lymph
auto
ABS

0.3

1.0-4.8

Low

91

91

95

MEDICATIONS (REPORT

Inadequate
nutrition
Pancytopeni
a
pancytopeni
a
pancytopeni
a
pancytopeni
a
pancytopeni
a
Heart failure
pancytopeni
a
pancytopeni
a
pancytopeni
a

SCHEDULED AND PRN MEDS THAT WOULD BE

ADMINISTERED DURING SHIFT)

Drug
Name

Dose,
Route,
Frequenc
y

Drug Class

Mechanis
m of
Action

Allopurinol

100mg
tab PO
QDay

Antihyperuricemic

Reduces
uric acid
synthesis

Benazopril

40 mg Tab
PO BID

Antihypertensiv
e

Inhibits ACE
to suppress
RAAS

Pt.
Perception/
Understandi
ng of Drug

Nursing
Consideratio
ns
(education
of drug)
Give with
meals, and
ensure
hydration

Top 3 Side
Effects

Hold if BP <
100/60 and
pulse < 60

Anxiety

Headache
Anorexia
Malaise

Hypotension
constipation

Carvedilol

12.5mg
Tab PO
BID

Antihypertensiv
e

Blocks beta
2
adrenergic
receptors

Assess BP and
pulse

Dizziness
Postural
hypotension
Diarrhea

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Hydrazalin
e

Protonix

100 mg
tab PO
TID

40 mg Tab
PO BID

Antihypertensiv
e

Proton pump
inhibitor

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Vasodialate
s arterial
smooth
muscles

Assess BP,
monitor
electrolytes

Suppresses
gastric
secretions

Take with
meals

Headache
Tremors
Dizziness
Headache
Diarrhea
Abdominal
pain

Docusate

20 mg PO
BID

Stool softener

Causes
stool to
retain water

Ensure
hydration

Diarrhea
Dehydration
Abdominal
cramps

Miralax

1 packet
PO qday

laxative

Draws
water to
stool

Ensure
hydration

Diarrhea
Dehydration

Avoid in
patient with
bowel
obstruction

Abdominal
cramps

Nursing Care Plan:

Nursing Diagnosis
A clinical judgment about an individual, family or
community response to actual or potential health problems
and life processes. Must be NANDA approved, with Related
factors (condition or etiology identified by assessment data)
included. Supportive statements may be added.
EXAMPLE: Impaired skin integrity r/t pressure point from bed
laying as evidenced by open skin wound on lower right back.
Short-term goal
Must be client centered: Pt will Focus on the specific
(Outcome)
behavior. Must be measurable response or behavior.
Attainable and realistic and based on client needs and
resources. Reflects clients highest possible level of wellness
and independent function.
Must be time limited (goals can be short or long term goals)
REMEMBER SMART!
EXAMPLE: Patient will change positions at least every 2 hours
while laying in bed and sit in chair at bedside 3 times each
day during mealtime.
Nursing
A list of treatments or actions that nurses perform to meet
Interventions
clients outcomes. These interventions should promote goal

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attainment, but are directed primarily at getting rid of the

etiology NOT the problem. Based on scientific rationale or
evidence based. Can be nurse initiated, physician initiated, or
a collaboration of care. Written in the present tense as if any
nurse could pick it up, read it and know what to do. Include
all appropriate interventions. They should be precise, indicate
frequency, indicate quantity, or method when appropriate.
EXAMPLE: 1. Nurse will round every hour to check on
patients position and to assist in a change of position every 2
hours while patient in bed. 2. Nurse will assist client to the
bedside chair at least 3 times a day during mealtimes. 3.
Nurse will assess lower back and watch for improvement in
skin wound (decreased swelling, redness, exudate, with edges
becoming more approximated) 4. Nurse will consult and refer
client to the wound care team and follow any wound care
orders as advised.
All interventions should have a scientific rational basisthe
reason you chose a specific intervention --and is based
on supporting evidence. Each needs to include a reference
or source whenever possible.
Refers back to the goal. Whether or not it was met,
partially met, or not met at all. Use specific statements or list
examples of patient achievement or lack of
achievement.
EXAMPLE: Patient turned at least every hour while in bed and
avoided laying directly on wounded area throughout shift.
Patient was awake and alert and sat on chair for all meals
today without any noted problems. Wound site remains open
with redness and exudate present. Wound care team visited
today and left orders for wound care. Goal partially met. No
need for revision at this time.

(Diagnostic)
(Therapeutic)
(Educational)

Scientific Rationale
and Source
Evaluation and
Revision

NURSING CARE PLAN

PRIMARY NURSING DX
Nursing DX (PES)
Problem, Etiology,
and Symptoms.
List 3 top Nursing
Dx AND Complete
the following on the
priority Dx.

Patient has decrease cardiac output due to congestive heart failure. CHF
prevents the heart from pumping out adequate CO which leads to dyspnea,
SOB, headache, labile BP, fatigue, and malaise. If CHF is not treated the
patient will continue to experience decreased CO, and it will lead to further
complications in the other body systems.

Deficient fluid volume

Impaired physical mobility

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Short Term Goal

(Outcome to
accomplish during
shift)

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Dysfunctional family process

1. The patient will demonstrate adequate CO as evidenced by blood

pressure, pulse rate and rhythm within normal parameters for client; strong
peripheral pulses; maintained level of mentation, lack of chest discomfort
or dyspnea, and adequate urinary output; an ability to tolerate activity
without symptoms of dyspnea, syncope, or chest pain

2. Remain free of side effects from the medications used to achieve adequate
cardiac output

3. Patient/caregiver will verbalize understanding of prevention of tertiary

complication related to CHF

Intervention

1. I will administer medications prescribed to treat CHF

2. Monitor and report presence and degree of symptoms including
dyspnea at rest or with reduced exercise capacity, orthopnea,
paroxysmal nocturnal dyspnea, nocturnal cough, distended
abdomen, fatigue, or weakness. Monitor and report signs including
jugular vein distention, S3 gallop, rales, positive hepatojugular
reflux, ascites, laterally displaced or pronounced PMI, heart
murmurs, narrow pulse pressure, cool extremities, tachycardia with
pulsus alternans, and irregular heartbeat
3. I will teach the patient about preventing further complications of
CHF by monitoring such as kidney function regularly.

Scientific Rationale

1. This will help the patients body to function properly and provide
adequate CO
2. These are symptoms and signs consistent with heart failure (HF) and
decreased cardiac output. In a study of primary care clients,
breathlessness during exercise, limitations in physical activity, and
orthopnea were the three most significant symptoms most often
associated with CHF
3. Preventing further complications can help the patients longevity
and quality of life.

Long Term Goal

(Outcome to
accomplish by/ upon
discharge)

1. Patient/caregiver will verbalize understanding of S/Sx to report

2. Patient will check BP q6hr at home
3. Patient will take medications as prescribed to treat hypertension and

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CHF
Intervention

1. I will teach the patient/caregiver about s/sx to report to a physician,

and when to seek medical treatment
2. I will teach the patient how to check BP, and show them BP
machines they can purchase at a local store. I will also inform them
of normal and abnormal BP readings
3. I will explain the importance of the medications the patient is taking,
and how they will help with her illnesses

Scientific Rationale

1. Understanding s/sx to report can help catch problems early and save
the patients life
2. Checking the BP at home can help the patient identify when the BP
is abnormal and when to seek medical treatment. It can also prevent
the patient from taking medications when the BP is too low.
3. When a patient understands the importance of a medication, they
are more likely to take the medication to aid in their healing process.

Evaluation and
Revision

The patient/caregiver were very receptive to the information I presented,

and agreed to use my suggestions at home. The caregiver stated that they
check the patients BP at home once a day, but he realizes the need to
check it more often.

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EVALUATION

OF

CARE GIVEN

1.

What did you observe during the patient interactions with others? What does this tell you about how the family
and/or patient is coping with this hospitalization?
I was unable to really communicate with the patient due to the language barrier; our communication was
translated through her son. I am unable to tell if he properly translated my messages. They argued quite a bit
when I was asking questions. Overall the patient seems relaxed, but ready to go home. The caregiver seem
really nervous and frustrated due to being presented with so much new information.

2.

In what ways did you use the Franciscan Values with your patient, patients family or other members of the
health care team?
I demonstrated dignity to the individual by providing excellent care to the patient and
educating the patient.

3. What clinical skills, patient education (safety, medication, call light, etc), teaching, and holistic care
were you able to perform?
Teaching- S /sx to report, the mechanism behind the medications, safety precautions, hand hygiene,
nutritional needs, and how to understand BP readings, call light,

4. How did your patient condition compare with the textbook picture?
My patients condition matched the textbook due to the hypertension and CHF. The patient
experienced the textbook stated symptoms of complications of CHF.

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5. Evaluate effectiveness of your nursing skill. What concerns do you have? Where did you need
improvement? Where were you strong?
Iwasstronginthebasicnursingskillssuchasambulationandteaching.Myweakareaisthedrugs
andknowingtheirpurposeandactions.IwillneedtocontinuereviewingpharmacologytoensureI'm
preparedtoadministerdrugssafely.Ialsoneedtounderstandwhentowithholddrugsduetothe
patientsvitalsigns.

6. What teaching were you able to accomplish for the client and/or family?
I was able to teach the patient/caregiver s/sx to report, the mechanism behind the medications, safely
precautions, hand hygiene, nutritional needs, and how to understand BP readings

7. What areas of skill or type of patient would you like to explore in your next clinical experience
I would like to work with a patient that require starting an IV, giving an injection,
and tracheostomy care.

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