CSU, STANISLAUS B.S.N.

CLINICAL PLAN OF CARE

Patient Data

Student ALYSSA CARDINAL Date of Care: 2/26-2/27/15

Room Number: S47

41

Code Status: Full

Pt. Initials: D.S. Gender: MALE Age: 55 Height: 511 Weight: 82kg (180lb) BMI: 25.1 Spirituality: Non-specified Ethnicity: CAUCASIAN
Admitting Diagnosis: ASPIRATION PNEUMONIA (r/t COPD exacerbation)
Vital Signs (2/27 1215): Temp: 98.3 HR: 104 RR: 22 B/P: 135/80 O2 Sat: 98% RA (Trach collar)
Pain Scale & Scale Type: 8/10 (0-10 scale)
History related to this admission: COPD, ASTHMA
Past Medical History: UPPER ESOPHAGUS METS TO A SUPRACLAVICULAR NODE (Dx 2014)- has undergone 3 cycles chemo/XRT,
TRACHEOSTOMY, HTN, LUMBAGO, PAIN IN LIMBS, PVD-INTERMITENT CLAUDICATION, TOBACCO USER, DISORDER OF KIDNEY AND
URETER (unspecified), COPD, HYPERLIPIDEMIA
Surgical History & Date:

Difficult intubation (6/3/14)

MD: Olgun, Esra
Diet: Clear liquids (as tolerated); PEG feeding w/ Osmolite 1.2, 2016 calories, 93g protein
Activity: bed rest with 1 person assist to bedside commode
Foley: none
Advance Directive: Yes ________ No ___X____

Feeding Tube & Rate: PEG- Osmolite 70mL/hr

Drains/ Tubes: PEG, Trach (placed 10/10/14, SZ 6
Shiley)
Glucose Monitoring: Q6h

Isolation: no
VS Freq: Q4H
DVT Prophylaxis: Active ROM, SCDs (pt refuses), position changes
Vascular Access:
IV Site: Peripheral- rt hand IV Solution & Rate: NS 50mL/hr
IV Site: Implanted port, rt infraclavicular fossa- (no access until blood cultures come back negative) PCA/Epidural: none
Telemetry & Rhythm: 5 lead; 0300- sinus tachy- HR 116
Safety Considerations: Aspiration precautions, Fall risk, Pressure ulcer prevention
Restraints: none
Labs for day of clinical: CBC, phosph, Mg+
Dressing Changes & Frequency: PEG dressing change Qshift, Trach care Q12h
Scheduled Procedures: sputum culture, stool
culture
Procedures done this admission: EKG (2/27/15 )- rate 126, sinus tachy, normal intervals, no STEMI
CXR (2/24 2225)- cardiomegaly, small pleural effusion, no pneumothorax
CT w/ Contrast (2/25 12:04AM)- bilateral lung nodules and mass in RLL, metastatic disease, pleural space unremarkable, no significant effusion, no
pneumonia, trace pericardial effusion, CA calcifications, no PE, trach tip in good location, old bilateral rib fractures, cyst in dome of rt lobe liver,
small hiatal hernia; Echo w/Doppler (2/25 1600) r/t syncope
Oxygen: RA w/humidification via T-piece Respiratory Treatment: Yes; ipratropium/albuterol (Duoneb) Q6h
Vent Settings: not on vent
Advanced Hemodynamic Monitoring & Values: None
IV Drips Medications Dosage & Rate: none (IV antibiotics listed in Meds)

Concept Mapping

Student Name: _Alyssa Cardinal__

List NANDA nursing diagnosis, supporting data, and interventions. List Supporting Data under each nursing diagnosis to support each diagnosis,
including lab data, medications, assessment findings in clockwise order. List Interventions for Each Nursing Diagnosis. All medical & nursing
interventions should be found in one or more of the boxes. Evaluate Each Nursing Diagnosis on the following page.

2. Impaired Gas Exchange

Data to Support:
Dx of COPD, coarse crackles, resp labored
with activity; RR=22 resting, RR
w/activity
Interventions:
Assess O2 sat, administer O2 during
periods of dyspnea, administer humidified
RA to liquefy congestive secretions and
improve breathing, elevate HOB to improve
effectiveness of respirations. Meds: Duoneb
(bronchodilator) and Advair
(corticosteroid)- gas exchange by opening
the airways, assess ABGs
3. Excess fluid volume
Data to Support: Dx of
COPD, coarse crackles in
lungs, generalized edema
Interventions:
Auscultate lung sounds,
Monitor I&O
(Consult with physician to
consider starting pt on
diuretic therapy)

1. Ineffective airway management

Data to Support:
Trach, thick, copious secretions, difficulty expelling secretions
Interventions:
Assess O2 sat, RR and ease of breathing, administer O2 during periods
of dyspnea, administer humidified RA to liquefy congestive secretions
and improve breathing, elevate HOB to improve effectiveness of
respirations. Encourage cough and assist with cough as needed. During
episodes of partial or complete airway occlusion r/t mucous plug,
rapidly push 10mL NS directly in to trach to mobilize secretions and
assist with expulsion. Meds: Duoneb (bronchodilator) and Advair
(corticosteroid)- gas exchange by opening the airways

Chief Medical Diagnosis: COPD

Priority Assessments:
Pt is at risk for respiratory failure, so monitoring lung
sounds, RR, ease of breathing, and O2 sat is crucial.
Pt also has a trach, cancer, and PVD, so trach patency,
pain management and effective tissue perfusion are
important for this pt as well.

4. Anxiety r/t pain management

Data to Support: Pt frequently requesting pain
medication and asking when the next dose of
Dilaudid or oxycodone can be administered, pt
appears agitated prior to administration of pain
meds
Interventions: Assess pts pain level and
administer pain medication on time, write
analgesic schedule on pts whiteboard to relieve
anxiety of when next dose will be administered,
reassure pt that his pain meds will be received as
quickly as possible to manage pain levels,
(Consult with physician to consider adding an
anti-anxiety to pts medication list)

5. Risk for aspiration

Data to Support: Dx of COPD
(excessive fluids) with trach and
difficulty expelling mucous,
ineffective/depressed cough, heavy pain
medication administration, decreased
GI mobility and tube feedings, impaired
swallowing, previous aspiration on
admission
Interventions:
Assess cough, gag reflex, swallowing
ability, auscultate bowel sounds for GI
motility, assess lung sounds for
crackles/ronchi, suction as needed,
elevate HOB, check GT tube residuals

6. Risk for bleeding

Data to Support: Platelet count 32,
multiple scattered bruises on lower
extremities
Interventions:
Assess skin for wounds, bruising,
prolonged bleeding at puncture sites,
monitor PLT count and coagulation
studies (no PT/INR in pt labs), monitor
VS for decreased BP and increase, use
soft toothbrush and electric razor to
prevent injury, fall precautions.

Student Name: __Alyssa Cardinal__

Problem Evaluation
Problem #
1

Evaluation of Patient Response

(0800)- O2 sat 96% on humidified RA, generalized coarse crackles, RR 19, no
dyspnea. HOB elevated. Infrequent mildly productive cough.
(0845)- Dyspnea r/t mucous plug occluding airway. FiO2 increased, O2 sat
dropped to 91%. Removed pts inner cannula and flushed trach w/ NaCl x3. Pt
coughed and expelled plug. O2 sat increased to 98%. Inner cannula replaced.
(0900)- Meds administered
(0930) Crackles in bilateral bases, no dyspnea
(0800)- O2 sat 96% on humidified RA, generalized coarse crackles, RR 19, no
dyspnea. HOB elevated. Infrequent mildly productive cough.
(0845)- Dyspnea r/t mucous plug occluding airway. FiO2 increased, O2 sat
dropped to 91%. Removed pts inner cannula and flushed trach w/ NaCl x3. Pt
coughed and expelled plug. O2 sat increased to 98%. Inner cannula replaced.
(0900)- Meds administered
(0930) Crackles in bilateral bases, no dyspnea
(0800)- Generalized coarse crackles, intake- 120 mL/hr, output- 375mL
(0930) Crackles in bilateral bases
(1030)- Intake- 120 mL/hr, output 250mL
(0715) Anxious behaviors r/t pain. Pt continuously asks for pain medication
schedule. Pain 7-8/10.
(0745) Administered Dilaudid.
(0800) No observable anxious behaviors, pain 5/10.
(1010) Anxious behaviors r/t pain. Administered oxycodone.
(1030) No observable anxious behaviors, pain 5/10.
(0800)- Infrequent, mildly productive cough. Generalized coarse crackles.
Adequate swallow. BS active x4.
No gastric residual. HOB 45 degrees.
(0930) Crackles in bilateral bases
(0800)- PLT count 32, scattered bruises on lower extremities, no current bleeding
from puncture sites. Generalized coarse crackles. BP127/76, HR 116. Fall risk
and bleeding precautions implemented.
(0930) Crackles in bilateral bases
(1215) BP135/80, HR 104

Medication: Generic
& Trade Name, Dose,
Route, Frequency

Mechanism of Action & Class

Pt Specific Rationale

Nursing Considerations (Assessment implications, S/Es, reasons to hold

med, admin rate, etc.)

vancomycin 1250mg
in 250mL NS, IVPB
Q12h

Tricyclic glycopeptide antibiotic; primarily

inhibits bacterial cell wall synthesis to destroy
bacteria and treat infection.

Pt has extremely elevated WBC

indicating infection. Vanco will tx
the pt's infection.

Hypokalemia (CHECK K+), n/v/d, cardiac arrest, hypotension, C.diff;

Infuse over 1 hour

fluticasone propionate
salmeterol (Advair),
250mcg/50mcg oral
inhalation, 1 puff
Q12h

Adrenal glucocorticoid, anti-inflammatory,

corticosteroid; Glucocorticoids inhibit mast
cells, eosinophils, basophils, lymphocytes,
macrophages, and neutrophils, while also
inhibiting production or secretion of cell
mediators such as histamine, leukotrienes,
cytokines and eicosanoids.

This pt has COPD and asthma. This

drug will reduce inflammation and
prevent exacerbations.

Candidiasis of mouth- rinse after use. Cough, nosebleeds, upper

respiratory infection, pneumonia- observe for sx of infection and monitor
WBC. Teach pt that this drug is not for acute attacks and may take a few
weeks to see results. Plug trach during administration of this med.

metronidazole
(Flagyl); 500mg in
100mL NaCl IV Q8h

Antibiotic; selectively produces cytotoxic

effects in anaerobes by a reduction reaction,
depriving the organism of required reduction
equivalents.

Pt has extremely elevated WBC

indicating infection. Vanco will tx
the pt's infection.

Abd discomfort, n/d, peripheral neuropathy, ototoicity; Infuse over 1

hour

piperacillin
sodium/tazobactam
sodium (Zosyn),
3.375g in 100mL NS
IVPB Q8h
acetaminophen
(Tylenol) 650 mg oral
Q4h PRN

Penicillin antibiotic; a bactericidal that inhibits

bacterial septum formation and cell-wall
synthesis to treat infection

Pt has extremely elevated WBC

indicating infection. Vanco will tx
the pt's infection.

constipation or diarrhea, n/v, fever, C.diff, pancytopenia; Infuse over 1

hour

analgesic/antipyretic- centrally acting COX-2

inhibitor that elevates the pain threshold,
thereby reducing pain levels. Reduces fever by
inhibiting the formulation and release of
prostaglandins.

This pt has pain constant aching

pain caused by trach and cancer.
This med will treat his fever.

4 g/day max to prevent liver failure (hepatotoxicity, GI hemmorhage, or

nephrotoxicity). Stevens-Johnson syndrome. Take with full glass of water

hydralazine
(Apresoline), 10mg IV
Q4h PRN for SBP >160

Peripheral vasodilator/antihypertensive;
relaxes vascular smooth muscle by interfering
with Ca+ movement responsible for initiating
or maintaining the contractile state within
vascular smooth muscle.

Pt has HTN. This med acts quickly to Administer each 10mg over 1 minute. Hepatotoxicity, agranulocytosis,
reduce BP.
n/v/d, loss of appetite, chest pain, palpitations, tachyarrhythmias.

Hydrocodone/
acetaminophen
(Norco-10)
10mg/325mg 1 tab
oral Q4h PRN

Opioid agonist analgesic; Acts on the CNS to fill This pt has pain ranging between 7
opioid receptors causing pain relief
and 9. This med will reduce his pain
to enhance comfort and reduce
anxiety r/t pain.

n/v, dizziness, Stevens-Johnson syndrome, agranulocytosis (check WBC),

thrombocytopenia (check plt count), hepatotoxicity, respiratory
depression (check RR before and after administration). Do not exceed
more than 4000mg acetaminophen daily. Teach pt to report s/s of resp
depression. Do not ambulate after administration of this med due to
dizziness.

hydromorphone
Opioid agonist analgesic; Acts on the CNS to fill This pt has pain ranging between 7
(Dilaudid), 2mg IV Q3h opioid (mu) receptors causing pain relief
and 9. This med will reduce his pain
PRN
to enhance comfort and reduce
anxiety r/t pain.

Constipation, n/v, hypotension, resp. depression, apnea, avoid activities

requiring mental alertness. Administer over 2 minutes.

ipratropium/albuterol
(Duoneb), 0.5 mg/ 2.5
mg/ 3 mL, oral
inhalation Q6h RT

Beta 2 adrenergic agonist/ bronchodilator/

sympathomimetic/ anticholinergic. Albuterol is
a sympathomimetic/beta 2 agonist that
activates these receptors to relax the smooth
muscles of the airway. Ipratropium is an
anticholinergic that produces a local effect
(opposed to systemic) that causes
bronchodilation.

This pt has COPD with a recent

exacerbation. It is therefore
important to maintain a relaxed,
dilated airway to enhance
oxygenation and prevent another
exacerbation. This is a short acting
med in comparison to the
Symbicort.

This med can cause GI disturbances, upper resp. infections, arrhythmias,

bronchospasm, blurred vision and dizziness. Remain in bed after
administration of this med to prevent falls.

sucralfate (Carafate),
1g/10mL, 1 g Q10-
30min before meals
and at bed

Antiulcer; forms an ulcer-adherent complex

with proteinaceous exudate, such as albumin
and fibrinogen, at the ulcer site, protecting it
against further acid attack. Also forms a barrier
on the stomach to protect from further
damage.

This pt is receiving many

Constipation, albumin toxicity in pts with renal failure
medications that cause GI irritation.
This med will prevent acid
erosion/irritation of the stomach
lining to prevent GI ulcers.

ondansetron (Zofran),
2mg/mL, 4mg IV Q6h
PRN

Antiemetic, Serotonin receptor antagonist;

Prevents nausea by blocking 5-HT3 receptors
peripherally on vagal nerve terminals and
centrally in the chemoreceptor trigger zone.

oxycodone
(Roxicodone), 10mg
oral tab Q6h PRN
temazapam (Restoril),
15mg oral cap at bed
PRN insomnia

This pt is in constant pain and has

anxiety r/t his pain. This often leads
to nausea. This med will reduce the
pt's nausea, making him more
comfortable.
Opioid agonist analgesic; Acts on the CNS to fill This pt has pain ranging between 7
opioid (mu) receptors causing pain relief
and 9. This med will reduce his pain
to enhance comfort and reduce
anxiety r/t pain.

Constipation, diarrhea, increased liver enzymes, headache, fatigue,

malaise, prolonged QT interval

Benzodiazepine/Hypnotic; Enhances the

effects of GABA to produce a calming effect on
the body.

Hypotension, somnolence, lethargy, avoid activities requiring mental

alertness, teach pt to report abnormal thoughts/behaviors. This drug is
not taken on a regular basis, used as needed for insomnia.

This pt has anxiety r/t pain, which

often causes insomnia. With an
unstable, unfamiliar hospital
environment, it is easy to become
anxious. This med helps ease
anxiety to make sleep easier.

Constipation, n/v, hypotension, resp. depression, apnea, avoid activities

requiring mental alertness.

LABS

Normal
Range

RESULT
1

RESULT
2

RESULT
3

(2/24)
2155
23.1 H

(2/25)
0406
27.0 H

(2/27)
0421
26.5 H

Reason for abnormal lab values r/t diagnosis & nursing implications

(Fill in Hospital
Norms)

CBC
WBC
RBC

4.0-11.0

Infection likely r/t aspiration on admission

Cancer causes decreased RBC production

3.9-5.4

3.62 L

3.62 L

2.75 L

Hemoglobin

11.7-15.5

12.5 L

12.4 L

9.3 L

Cancer causes decreased RBC production

Hematocrit

35-47%

34.2 L

34.8 L

26.6 L

Cancer causes decreased RBC production

MCV

80-100

95

96

97

MCH

27-33

34.5 H

34.3 H

33.8 H

MCHC

31-36

36.5 H

35.6 H

35

RDW

<16.4%

15.3

15.3

15.6

PLT COUNT

38 LL!

Poorly oxygenated blood

This pt is not on any blood thinners or other medications that reduce plt count. The reason for thrombocytopenia is
unknown- This pt does have a bacterial infection which can cause destruction of platelets. This pt could also has
PVD which can lead to clotting and therefore a large abundance of platelets in one area, reducing the total systemic
platelet count.

150-400

35 LL

32 LL

49-74%

78% H

71 H

Infection

11 H%

19 H

Infection
Infection

WBC DIFF
NEUTROPHIL
%
BANDS %
LYMPHOCYTE
%

26-46%

1L

1L

MONOCYTE %

49-74%

6%

Sodium

136-145

120 L

121 L

130 L

Potassium

3.5-5.1

3.4 L

3.7

Chloride

98-107

83 L

82 L

95 L

CO2(bicarb)veno
us

21-32

31

29

27

Glucose

70-99

93

107 H

128 H

CHEMISTRY

HbA1C

This pt has had diarrhea prior to admission which causes hyponatremia. However, he has been on continuous IV
NS since admission. Treatment team should consider increasing rate of IV NS to normalize sodium levels.

High stress levels on the body, including the heart, cause an increased glucose level. The pt is also on a
corticosteroid for COPD, which can cause hyperglycemia.

8.2

7.5 L

Low calcium levels are likely r/t malnourishment, as kidney function tests came back normal. Because this pt
hasn't had a BM in 3 days and has abd distention, there is a possibility he has an ileus, leading to poor nutritional
absorption and therefore hypocalcemia.

2.5-4.9

2.9

7.5 L

Poor oxygenation leads to impaired cellular energy (ATP), which has a direct effect on phosphorous levels

Magnesium

1.8-2.4

1.8

BUN

6.0-25

Calcium

8.2-10.2

phosphorus

Creatinine

7.4 L

0.6-1.10

HDL

0-100

LDL

0-200

Cholesterol

0-150

0.77

0.78

Triglycerides
LIVER PANEL

6.4-8.2

Total protein
Albumin
Bilirubin Total

0-1.1
26-137

Alk phosphatase

0-37

AST

0-60

ALT

73-393

Lipase
Amylase
Ammonia
Lactate
Serum Ketones
CARDIAC
PANEL
CPK
CPK-MB
Troponin I

0-0.5

2.02

0-300

3415

Myoglobin
BNP
COAGULATTI
ON
PT
INR ratio

High BNP=CHF!! Although this pt does not have a dx of CHF, he does show many symptoms including fluid
overload (edema), HTN, and tachycardia.

PTT
Fibrin level
Bleeding time

D-Dimer

0-250

715

UA collection
type
Urine color
Urine
appearance
Specific gravity
Urine Ph
Urine glucose
Urine bilirubin
Urine blood
Urine Ketones
Urine Nitrites
Urine Protein
Urine
Leukocytes
URINE MICRO
WBC HPF
RBC HPF
Nitrate HPF
Epithelial
Bacteria
Mucous
URINE
CULTURE
CSF

WBC

0-5.0

RBC

0-2.0

Glucose

negative

negative

Protein

negative

negative

Testing D-Dimer is important when there is a suspicion of deep venous thrombosis (DVT), pulmonary embolism
(PE) or disseminated intravascular coagulation (DIC). This pt has thrombocytopenia, which could indicate a clot.
He also has PVD and a recent COPD exacerbation, which can lead to clots. An elevated d-dimer suggests he may
have a clot.

negative

negative

pH

7.35-7.45

7.545 H

alkalosis

PO2

80-100

63L

hypoxemia

PCO2

35-45

34L

respiratory alkalosis- r/t hyperventilation (COPD exacerbation)

Bicarbonate
Oxygen
Saturation

24-26

28.7 H

alkalosis

95-100

93

hypoxia

Anion gap

10-20.0

9.4 L

A low anion gap in this patient is caused by the COPD exacerbation and elevated HCO3-, resulting in metabolic
alkalosis. I would have liked to have seen an ABG for this patient.

Lactate

0.4-2.0

1.2

Culture

Blood Cultures
Stool Cultures
Nasal Cultures
ABG(FIO2 +
device)

Student Clinical Self-Appraisal

Weekly (turn in with Care Plan/Map)
Student: Alyssa Cardinal
Course: N4810
Instructor: Sherri Brown
Instructions: Please evaluate your performance during clinical today using the following concepts:
Client Advocate
Critical Thinking
Self-Initiated
Professional Accountability
Leadership
Nursing Process

Professional Demeanor
Communication/rapport
Technical skills
Organized
Well-prepared
Comprehensive Assessment

Areas of Strength Today (Date)

Flexible
Coordinator of Care
Team Player
Educator
Ability to Prioritize
Knowledgeable

Areas Needing Growth-Include plan of

improvement

Critical thinking: This pts case was very complex and I feel
I did well thinking outside of the lines to determine some of Organized: My organization this week was far better,
his clinical manifestations.
but I could definitely use improvement in this area.
Technical skills: I felt so much more comfortable using the
monitors and starting IV meds today.
Communication/rapport: I formed an excellent rapport
with my pt and nurse this week. This facilitated my
learning experience and made the day go by so much faster
and easier.

Knowledgeable: As Im still learning the pathophysiology

behind advanced heart and lung disorders and their
associated lab values and treatments, I need more time
learning and retaining these topics.
Comprehensive Assessment: Although I felt my
assessments were better this week, they still need the most
improvement.

Instructor Comments: Case Map problem #3- I loved your entire case map great job the only
thing I have issue with is your fluid overload. You need to support it more. I/0 ratio etc. Because
the trach secreations could be causing the airway changes. So you need to support it more,
you could have increase BP, more input then output. And other objective data. I love having
you in clinical you are a smart young lady who will be a great nurse. Make sure your entire care
plan matches throughout.

Student Name: Alyssa Cardinal

Date: 2/12/15

Clinical Instructor: Sherri Brown

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 ____20_

2.

Each medication includes:

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

20 points possible __18___

3.

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

10 points possible ____8_

4.

Problem Identification includes

20 points possible __20___
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 ___10__

6.

Evaluation of Interventions includes

a. Evaluates physical interventions
b. Evaluates teaching

10 points possible ___10__

7.

a.
b.

10 points possible __10__

Priority Assessments are appropriate to diagnoses

Clinical Paperwork is complete
Total Points

_________96____/100 = ____%