FAYETTEVILLE TECHNICAL COMMUNITY COLLEGE
ASSOCIATE DEGREE NURSING PROGRAM
NUR-114 CLINICAL PAPERWORK
Student Name:
Commented [F1]: Satisfactory. Well Done.
Date: 04/01/15
General Patient Information
Patients Initials: T Room #: 6803
Height: 157.48 cm
Age: 65
Sex: F
Date of Admission: 03/ 30/15
Weight: 181.6 kg
Allergies (explain type of reaction experienced): penicillin
Admitting Diagnosis: chest pain
Pertinent Health History/Surgeries: obesity hypoventilation syndrome, ventilator-dependent respiratory failure from
pneumonia, severe obstructive sleep apnea, diabetes type 2, hypertension, hyperlipidemia, neuropathy, anxiety
Code Status: Full Code
Isolation Precautions: Standard
Health Patterns Assessment (complete the following information)
Stated reason for hospitalization: chest pain in the lower retrosternal area.
What other health problems have you had? Asthma, tracheostomy with home ventilator, obesity, diabetes, high
cholesterol anemia, Atrial Fib.
Significant family medical history (Heart disease, cancer, diabetes) mother had Coronary Artery Disease.
Medications taken at home (include OTC and herbal supplements: albuterol sulfate, atorvastatin, Zyrtec, citalopram,
digoxin, vitamin B12, fish oil.
Do you take your medications as prescribed? Yes
Tobacco use (type and frequency) No
ETOH use (type and frequency) No
Non Prescribed Drug use (type and frequency) No
Exercise (type and frequency) No
Home Diet (number of meals per day, general description of diet) 3 meals a day, eating a lot of snack foods high in
saturated fats
Commented [F2]: Pt needs nutrition consult and diet education
Physical Assessment Findings:
1
Commented [F3]: Well groomed
Patients general appearance (well-groomed, poor hygiene, etc ): an obese woman
Behavior: cooperative
Vital Signs: BP 145/85 HR 87 RR 18 O2 Sat 97 % on BiPAP
Temp (specify oral, tympanic, axillary, rectal) 98.3 0 F oral
Pain rating (identify scale used): 7/10 on the pain rating scale
Onset: gradual
Frequency often
Location: lower extremities
Duration: for a long time
Radiation denies any radiation
Precipitating factors: tachycardia, blood pressure changes, neuropathy. Method of relief pain medication as prn and
order
Neurological:
Orientation: awake, alert, oriented X 3
Pupils/PERRL: equal, round, and reactive to light and accommodation Size (mm) N/A
Extremity Strength (equal bilaterally?) yes
Speech: patient can speak over the tracheostomy
Gag Reflex : yes Ability to swallow: yes
Eyes, Ears, Nose, Throat:
Sclera appearance, eye drainage, vision impairment, glasses/contacts, etc: glasses needed
Ear drainage, hearing impairment, hearing devices, etc: no hearing deficit, no hearing aid device needed
Nasal drainage, nares patent, etc: no nasal drainage
Throat appearance: a tracheostomy patient
Teeth (cavities, missing teeth, dentures, etc) no dentures, no missing teeth
Cardiovascular:
Heart sounds: no murmurs
Rhythm (regular/irregular) irregular rate and rhythm
Quality of pulse (bounding, strong, normal, weak, absent, Doppler) weak
Capillary refill: delayed capillary refill, more than 3 minutes
2
Cyanosis No
Bleeding precautions N/A
Edema (location, pitting/non-pitting, grade) redness and positive + 1 edema to lower extremity bilaterally
Telemetry:
yes
Identified cardiac rhythm controlled fib 57
Pacemaker N/A
Commented [F4]: Every number needs a value. So HR 57
Complaints of chest pain? No
IV access (include location, site appearance, date of insertion). Location: accessory cephalic left Date inserted 04/2/15
Site appearance: clean, dry
IV infusion (type of solution, rate of infusion) Type of fluid: Normal saline
Rate: 5ml/hr
Respiratory:
Pattern Normal
Depth Normal
Effort No
Lung sounds
Anterior: Right clear
Left
Posterior: Right clear
clear
Left clear
Cough No Productive N/A
Secretions (amount, color) No
Supplemental O2: on BiPAP at 40 % Complaints of shortness of breath? No
Trach yes
Gastrointestinal:
Bowel sounds: RUQ present RLQ present LUQ present LLQ present
Abdomen (flat, round, obese, soft, distended, firm, etc.) soft, obese, non- distended
Tenderness
no
Location: epigastric area
Last bowel movement yesterday morning
Nausea yes
Character, consistency: normal
Vomiting No
NG/OG/Dobhoff/Peg No
Placement confirmed: N/A
Residual N/A
Ostomy (type, location, stoma appearance): No
3
Hospital diet (include supplements and rationale, and route if applicable): soft, mechanical altered / chopped
Genitourinary:
Last void 0700 Appearance clear, yellow
Commented [F5]: via bedpan or BSC
Bladder (distended/ non-distended) non distended
Catheter type and size No
Date inserted N/A
Penile/vaginal discharge No
Dialysis: no
Incontinence No
Ostomy: no
Type/location N/A
Type: hemodialysis peritoneal dialysis
Hemodialysis access:
Appearance N/A
AV graft
AV fistula
N/A
Dialysis Catheter
Tenckhoff
Location: N/A
Date of dressing change N/A
Bruit No
Thrill N/A
Integumentary:
Characteristics (color, temp, condition) mild redness and thickening of the skin on the bilateral lower extremities
Turgor: loose skin turgor
General description of skin: cracked, dry
Wounds/Drains/Dressings (include location, appearance, and type) No
Musculoskeletal:
Range of Motion (full, contracted, and/or limited): patient is not mobile
RUE limited RLE limited
LUE limited LLE limited
Muscle tone (normal, decreased, increased, flaccid, atrophy, rigid, spastic)
RUE decreased
RLE decreased
LUE decreased LLE decreased
Amputations
no
Describe N/A
4
Ortho equipment
no
Describe: N/A
Gait (steady, unsteady, needs assistance, etc.) very unsteady gait, need assistance with all ADLs.
Discharge Planning (describe the needs of the patient during discharge planning):
Explain to Ms. T what is BiPAP for. Pt will need humidification bottle for home vent settings.
Encourage the patients to call for assistance as needed. Pt cannot perform ADLs.
Commented [F6]: I would say more about what she needs
when she gets home for EX home health aid to help with ADLs
Health Teaching (describe at least 2 teaching needs of the patient):
Ms. T will need to limit intake of foods that is high in saturated fat to control blood sugar and decrease level of
cholesterol. Focus on a low-fat diet and increased intake of fiber.
Commented [F7]: Excellent
Ms. T will need to reduce salt intake to help decrease blood pressure.
FAYETTEVILLE TECHNICAL COMMUNITY COLLEGE
ASSOCIATE DEGREE NURSING PROGRAM
NUR-114 Laboratory and Diagnostic Tests Data Sheet
Lab Values
Clients Value
(Normal, High, Low, Critical)
Describe the significance of the abnormal lab for
this patient
HEMATOLOGY
WBC
RBC
7.5 Normal
3.62 Low
HGB
9.3 Low
HCT
COAGULATION
Platelets
31.8 Low
Decreased RBCs below the normal value is
associated with anemia
Decreased levels indicate anemia (reduced number
of RBCS)
Decreased levels indicate anemia (reduced number
of RBCS)
198 normal
PTT
N/A
PT/INR
5
INR 3.8 PT 43.4 high
A longer than normal PT can mean a lack of or low
level of one or more blood clotting factor or lack of
vitamin K, liver disease or liver injury occurs
CHEMISTRY
Glucose
115 High
Pt has diabetes, hyperglycemia
Sodium
139 normal
Potassium
3.9 normal
Chloride
103 normal
Calcium
8.8 normal
BUN
8 normal
Creatinine
0.9 normal
Total Protein
Albumin
N/A
N/A
URINALYSIS
Color
N/A
Specific Gravity
N/A
N/A
pH
Ketones
N/A
Protein
OTHER LABS
CO2
Magnesium
N/A
Clients value
(normal, high, low, critical)
27 normal
1.5 Low
Describe the significance of the abnormal lab for
this client
Low magnesium levels may increase cardiac
irritability and aggravate cardiac arrhythmias.
Diagnostic Tests (other than labs)-Radiographic studies, ECG, Endoscopy, etc.
Date
Name of Test
Results
Implications
03/30/15 Chest X-ray
Cardiomegaly and some chronic interstitial
No acute findings
infiltrates
6
DATE
TIME
04/01/15 0900
ALL NOTES MUST BE SIGNED AND DATED
65 yr old obese white female admitted to the ED 03/30/15 for chest pain. VS: B/P: 145/85
HR 87 RR 18 T 98.3 0 F Pulse ox 97 % on BiPAP. Alert and oriented to person, place,
day/time and situation. Pt states having pain at lower extremities. Pain level 7 out of 10 on
the pain rating scale. ----------------------------------------------------------------------------HN, FTCC NS
Commented [F8]: number scale
Commented [F9]: due to obesity and increased oxygen needs.
Pt is on 40 % of the BiPAP via trach. Pt is unable to perform any ADLs without assistance.
Encourage patient to call for assistance as needed. Pt acknowledged understanding.HN, NS
Patient can speak over the trach and does PO med food 1+ pedal edema noted
Patient has clear lung sounds in the upper lobe bilaterally and slowly diminished
at lower lobes. No wheezing noted. Redness to lower extremities bilaterally. Pt is on the
telemetry monitor. --------------------------------------------------------------------------- ---HN, FTCC SN
Bowel sounds are present. Last bowel movement at 0700, normal. ---------------HN, FTCC SN
0910
ACCUCHECK: 115 mg/dL ------------------------------------------------------------------------------- HN, FTCC SN
0915
Monitor signs and symptoms for pain. Administer pain medication as prn and order. HN, FTCC SN
Commented [F10]: See MAR
0930
Administering medications, see MAR ---- ------------------------------------------------------------ HN, FTCC SN
1200
Remains on BiPAP via trach at 40 %. Trach supplies at the bedside. Pt is resting, offer no complains.
Sa O2 98 % at BiPAP, no respiratory distress noted. Respirations are even and unlabored. Telemetry
Call bell is in reach. Bed is in low position for safety. ------------------------------ -------------- HN, FTCC SN
Printed Name: HANH NGUYEN
Signature/Title: FTCC nursing student.
NURSES NOTES
7
Commented [F11]: Excellent notes. Just need some
organization. Well done
Fayetteville Technical Community College
ASSOCIATE DEGREE NURSING PROGRAM
NUR-114 Clinical Pathophysiology
Primary Medical/Surgical Diagnosis: Eating disorder: Obesity
Etiology: Obesity is defined as an excess accumulation body fat of at least 20 % over average desired for age,
sex, height or body index mass ( kg/m 2 ) of greater than 27.8 for men and greater than 27.3 for women. Obesity
is a chronic condition considered by some to be a disability.
Cause: eating unhealthy foods and overeating, sedentary lifestyle, physical inactivity, family history of
obessity.
Disease related to obesity:
- Diabetes mellitus
- Cerebrovascular accident (CVA)/ stroke
- Hypertension
- Myocardial infarction
- Heart failure
- Deep vein thrombosis
Clinical manifestation:
- Inability to engage in exercise
- Hypertension, edema
- Increased heart rate/ respirations with activity
- Dyspnea with exertion
- Weight disproportionate to height
- Pain/ discomfort on weight- bearing joints or spine
- Cyanosis, respiratory distress
Diagnostic Findings:
- Metabolic/ endocrine studies: may reveal abnormalities, e.g., hypothyroidism, hypopituitarism,
Cushings syndrome, hyperlipidemia, hyperglycemia, hypogonadism.
- Anthropometric measurements: measures fat to muscle ratio.
Medical / Surgical Management:
- Weight control incorporating healthful food. Limit saturated fats. Focus on low fat intake and increase
fiber diet.
- Avoid sedentary lifestyle, regular physical activity.
Secondary Diagnosis and brief description:
Type 2 diabetes: it is a problem with the body that causes blood glucose levels to rise higher than normal.
Medication Worksheet
Drug Name
Classification
Mechanism of
Action
Anticoagulant/thro
mbolytic
Inhibits Vitamin K
dependent coagulation
factor synthesis
2 mg po
daily
Lipid-lowering
agents
catalyzing an early
step in the
synthesis of
cholesterol.
Blocks stimulation
of beta
1(myocardial)
10 mg PO
TAB every
day
(trade/generic)
Warfarin/Coum
adin
Lipitor
antihypertensiv
es
Metaprolol
Antidiabetics,
hormones
Lower blood
glucose by
stimulating
glucose uptake
antidepressants
Selectively inhibits
the reuptake of
serotonin in the
CNS.
Insulin Lispro
(Humalog) 3
ML
citalopram
Dose,
Rationale for
Route,
taking drug
Frequency
50 mg PO
tab twice
a day
151 to
200 2
units
201 to
250 4
units
251 t0
300
6 units
301 to
350 8
units
351 t0
400
10 units
2000 mcg
PO TAB
Adverse side
effects
Nursing
consideration
s
Atrial Fibrillation
Hemorrhage:
reverse with
administration of
Vit K
Monitor PT/INE,
Plt
Lowering of
total and LDL
cholesterol and
triglycerides
Decrease BP
and heart rate
Abdominal
cramps,
constipation
heartburn
Fatigue,
weakness,
dizziness,
drowsiness,
insomnia
Erythema,
lipodystrophy
swelling,
allergic
reactions
including
anaphylaxis
monitor liver
function tests,
assess muscle
cramps
Monitor BP,
ECG and
pulse
frequently
Confusion,
drowsiness,
insomnia
Assess
suicidal
tenderness
Control of
hyperglycemia
in diabetic
patients
Antidepressant
action.
Assess for
symptoms of
hypoglycemia
NURSING CARE PLAN
Nursing diagnosis: chronic pain related to neuropathy as evidenced by verbalizing that pain is present, pain is
rated 7/10, crying at times, need assistance with ADLs, irritable with family members and caregivers
Patient goal: patient will demonstrate decrease in pain.
Nursing Interventions:
- Administering Tylenol 650 mg PO tab every 4 hour if needed, not more than 4 gm in 24 hours.
- Ask the patient to describe prior experiences with pain, effectiveness of pain management intervention
and response to pain medications including side effects, ask patient about pain intensity level using
numerical pain rating scale
- Keep monitoring signs and symptoms of pain.
Documented Rationale:
- Provide the basis to determine effectiveness of the individualized pain management plan.
Evaluation: patient verbalized pain rated 3/10 on a numeric rating scale.
APA References:
Ackley, B. J., & Ladwig, G.B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care
(10th ed.). St. Louis, MO: Mosby/Elsevier
Ignatavicius, D. D., & Workman, M. L. (2013). Medical-surgical nursing: Patient- centered collaborative care
(7th ed.). St. Louis, MO: Elsevier.
Pagana, K. D., & Pagana, T. J. (2010). Mosbys manual of diagnostic and laboratory tests (4th ed.). St. Louis,
MO: Mosby/Elsevier.
10
Commented [F12]: This is a good nursing diagnosis but look at
a diagnosis that relates to the primary diagnosis or the most
pertinent issue. Like her respiratory status.
