Formal Care Plan Student Name: Brittany Bonner A. Pathophysiology Disease 1.

Hypertension Clinical Dates: March 11, 2011

System/Organ 1. Circulatory/Vessels & Heart

2. Diabetes Mellitus 3. Pneumonia

2. Endocrine/Pancreas 3. Respiratory/Lungs

Etiology 1. Disease associated with genetic predisposition and family history; advancing age; gender; AfricanAmerican race; high dietary sodium intake; diabetes mellitus; cigarette smoking; obesity; heavy alcohol consumption; and low dietary intake of potassium, calciu 2. Disease results from genetic susceptibility, long standing obesity, and a sedentary lifestyle. 3. Aspiration of oropharyngeal secretions causes infection of the lower respiratory tract by bacteria, viruses, fungi, protozoa, or parasites.

Disease

Pathophysiological Changes Arterial pressure rises when there is an increase in cardiac output or systemic vascular resistance. Persistent elevation of SVR, is the hallmark of hypertension. Chronic hypertension damages vessel walls, causing permanent narrowing and constriction. It also impairs many body systems, especially the kidneys. Hypertension combined with CAD increases the risk of coronary artery occlusion and myocardial infarction. (Lewis, 2007 pg 764-766;Huether, 2008 pg 609)

Clinical Manifestations Typically asymptomatic, fatigue, reduced activity tolerance, dizziness, palpitations, angina, visual impairment edema and dyspnea (Lewis, 2007 pg 766; Huether,2008 pg 612)

Rationale Fatigue is caused by the hearts increased workload, reduced activity tolerance is due to the lack of O2 being supplied to muscles, and dyspnea and dizziness would be due to the inability of the heart to pump sufficient blood to the lungs and brain. (Lewis, 2007 pg 564-565;Huether, 2008 pg 609-612)

The pancreas produces some endogenous insulin, but it is either insufficient for the needs of the body and/or is poorly utilized by the tissues. Without insulin the body cannot transport glucose into the cell to be utilized for energy, therefore causing increased levels of glucose in the blood. 1.)Insulin resistance in glucose and lipid metabolism is due to insulin receptors that are either unresponsive to the action of insulin and/or insufficient in number. This results in the entry of glucose into the cell to be impeded, resulting in hyperglycemia, also the pancreas may respond by producing greater amounts of insulin (if beta cell function is normal), which creates a state of hyperinsulinemia that coexists with the hyperglycemia. 2.)The pancreas beta cells can become fatigued due to the overproduction of insulin in response to high blood sugar levels, or the beta cell mass may be lost. This can be due to chronic hyperglycemia or high circulating free fatty acids. 3.)The liver may produce glucose haphazardly that does not correspond to the bodys needs. 4.)Fat cells (adipose tissue) may interfere with the production of normal hormones and cytokines. The tissue produces adioponectin and leptin known as adipokines, which have a role in altered glucose and fat metabolism. (Lewis, 2007 pg 1255-1257;Huether, 2008 pg 464-465) Pt. aspirates the bacteria or virus, then WBC arrive which activate the inflammatory response, next exudate, RBC, and bacteria accumulate in the lungs, and the result is inflamed airway and fluid in lungs. Congestion: fluid in alveoli; Red Hepatization: massive dilation of capillaries, alveoli fill with organisms, neutrophils, RBCs, and fibrin; Gray Hepatization: blood flow decreases and leukocytes and fibrin consolidate in the effected part of the lung; Resolution: complete resolution and healing occur if there are no complications, the exudate becomes lysed and macrophages process it, normal lung tissue is

Fatigue, recurrent infections, recurrent vaginal yeast or monilia infections, prolonged wound healing, parasthesias and visual changes (Lewis, 2007 pg 1258;Huether, 2008 pg 465-468)

Fatigue may be caused by the constant state of disequilibrium due to the excess of glucose in the blood, prolonged wound healing may be due to peripheral neuropathy, and/or decreased circulation. (Lewis, 2007 pg 1254-1257;Huether, 2008 pg 465-466)

Fever, chills, shortness of breath, cough productive of purulent sputum or dry cough, and pleuritic chest pain, malaise, dyspnes, confusion or stupor, dullness to percussion, increased femitus, bronchial breath sounds and crackles, elevated WBC count. (Lewis, 2007 pg 564-565;Huether, 2008 pg 733-734)

Fever is the bodys systemic inflammatory response to an infection, shortness of breath is caused by fluid buildup in the lungs resulting in short, shallow breaths, and the crackles heard in the lungs are caused by the alveoli expanding through the fluid.(Huether, 200 pg 732-734)

restored, gas-exchange ability returns to normal.(Lewis, 2007 pg 564-565;Huether, 2008 pg 733)

B. Summary of Hospitalization & C. Disease Relationship Pt. Initials: PG Admit Date: 3/9/2011 Allergies and Reactions: NKA Age: 77 Sex: F POD ____ Code Status: Full

Allergy bracelet on: N/A

Summary of Hospitalization: 3/6/11: Pt. stated she was feeling worse with a fever of 101oF and cough with SOB. 3/7/11: temp was 99.8oF and pt. felt weaker. 3/9/11: was sees by her primary physician in the office; O2 was low @ 88% even with supplemental oxygen. Pt. was admitted to the hospital. Pt. presented with leukocytosis and fever, upper respiratory tract infection: pneumonia. Pt. admitted for evaluation of SOB and concern for atrial fibrillation. Pt. is also in pain due to recent right rotator cuff injury. Pt. has hx of diabetes mellitus, obstructive sleep apnea, hypertension, CAD,hypercholesterolemia, chronic dyspnea, COPD, asthma, a-fib, and chronic renal insufficiency grade 4. Pt. has partial thyroidectomy and is awaiting surgery on right rotator cuff. Baseline labs: creatinine 2.7; Bun 51; GFR of 12; Na+ 133; K+ 4.7; platelet count 239,000; WBC 12.3; Hgb 10.1; Hct 29.5. Pt. is in normal sinus rhythm. Pt. doesnt smoke or drink. Pt. is obese. BP 136/64; HR 72; RR 20; temp. 95.9. Pt. has no edema. Pt. is on diabetic diet. Pt. has left anticubital IV with normal saline running @ 50ml/h. Pt. was started on heparin therapy. After a round of labs including BMP, CPK-MB, troponin, a UA, BUN & creatinine, Glucose, CBC, and electrolytes and several diagnostic tests including chest x-ray, 2D Echo, chest CT, and renal panel; ischemia and MI are ruled out. Leukocytosis, fever, and upper respiratory tract infection lead to the diagnosis of pneumonia. Pt. has stable pleural fluid and mild atelectasis in right lung base, no pneumothorax, right lung clear with small right pleural fluid collection. Pt. is also found to have moderate pulmonary hypertension, mild tricuspid insufficiency, and sclerotic aortic valve. Pt. was started on O2 therapy upon admission but has been weaned off and is at 95% O2 saturation on room air. Pt has received Rocephin and Zithromax and is taking Norco for pain. Pt. is improving. She is ambulating with assistance but becomes fatigued easily. Pt. is consistently rating her pain as a 2 or less. Pt. was visited by daughter on 3/11/11 and appeared calm and happy. Disease Relationships: Diabetes is detrimental to several organ systems, especially the kidneys, and may be the cause of the pt.s renal insufficiency. Hypertension has contributed to valve insufficiencies and stenosis in the heart. Obesity and sedentary lifestyle add to the pt.s risk for diabetes and hypertension. Hyperlipidemia with concurrent hypertension increases the pt.s risk for atherosclerosis and clot formation. Because fat deposits and clot formation frequently occur in the coronary arteries, this patient is at risk for ischemia and acute myocardial infarction. Atrial fibrillation also leads to an increased risk for clot formation in the artria that can be ejected into the lungs causing pulmonary embolism or stroke. COPD and asthma predisposed this patient to bacterial infection of the lower respiratory tract due to pulmonary inflammation and decreased functionality of the lungs.

D. Medications(10 points) Student: Brittany Bonner Pt. Initials: PG Name & Classification Include Med Order calcitrol 0.25mcg PO daily Allergies, reactions: NKA Reason for Medication Pt has renal insufficiency and calcitrol promotes renal retention of calcium.

Clinical Dates: 3/11/2011 Wt. (Kg/lb): 238 Side Effects

Recommended Dose Adult: PO 0.25mcg/d

Action

Key Nursing Implications

clonidine; Catapres 0.1 mg PO TID

Adult: PO 0.1 mg BID or TID

Pt. is diagnosed with hypertension.

Promotes intestinal absorption and renal retention of calcium, calcitrol elevates serum calcium levels, decreases elevated blood levels of phosphate and parathyroid hormone. Thus it decreases subperiosteal bone resorption and mineralization defects. Decreases systolic and diastolic BP and heart rate.

Muscle or bone pain, palpitation, anorexia, N&V, constipation, metallic taste, vitamin D intoxication, headache, weakness, blurred vision, photophobia, increased urination.

Monitor serum calcium levels for hypercalciemia.

Fluticasone salmeterol Advair 250/50 1H BID insulin glargine; Lantus 45 units SQ HS

Adult: 1-2H q12h

Pt. diagnosed with COPD and asthma.

Reduces inflammation in the bronchial tree.

Hypotension, peripheral edema, ECG changes and tachycardia, bradycardia, flushing, rapid increase in BP with withdrawal, dry mouth, constipation, drowsiness, sedation, dizziness, headache, dyspnea, fatigue, weakness, decreased libido. Candidal infection of the oropharynx, hoarseness, dry mouth, sore throat and mouth. Hypoglycemia

Monitor BP and HR closely.

Educate pt of proper use and oral hygiene.

Adult Type 2 Diabetes: start at 10 Units SQ then adjust to pts needs.

Pt. is diagnosed with Type 2 Diabetes, and has unstable BS on oral hypoglycemic alone.

Lowers blood glucose level over an extended period of time. It also prevents the conversion of glucagon to glucose in the liver.

Monitor for S&S of hypoglycemia. Withhold drug and notify physician if pt is hypokalemic.

nifedipine 90mg PO daily

Adult Hypertension: PO 10-20mg TID up to 180mg/d

Pt. is diagnosed with hypertension.

Decreased peripheral resistance, leading to a rise in peripheral blood flow and lowers peripheral vascular resistance. Ipratropium: produces local, site-specific effects on the larger central airways including bronchodilation and prevention of bronchospasms. Albuterol: bronchodilation decreases airway resistance, facilitiates mucus drainage, and increases vital capacity. Anti-inflammatory and immunosuppressive properties

Dizziness, lightheadedness, facial flushing, heat sensation, peripheral edema, diarrhea, hepatotoxicity. Cough, tremor, N&V.

Ipratropium albuterol Duoneb 0.5-2.5mg/3ml neb daily & PRN

Adult inhaled: 0.5 ipratropium & 3mg albuteral per 3ml

Pt. is diagnosed with COPD and asthma.

Monitor BP carefully. Withhold drug and notify physician if systolic BP<90. Monitor blood sugar in diabetic patients. Monitor for gingival hyperplasia. Monitor respiratory status; auscultate lung sound before and after therapy. Monitor for S&S of fine hand tremors

methylpredisolone Solu-Medrol 40mg IV Q8h

Adult IV: 10-40mg PRN or 30mg/kg Q4-6h x 48h.

Pt. taking this med to decrease inflammation and pain of injured rotator cuff or as short-term therapy of acute bronchial asthma. Pt. is diagnosed with hypertension.

Headache, edema, N&V, muscle weakness, delayed wound healing, osteoporosis, spontaneous fractures, hypokalemia.

nebivolol HCl Bystolic 5mg tab PO daily

Adult hypertension: PO 5mg daily

A beta-adrenergic receptor blocker that decreases both systolic and diastolic pressures associated with hypertension.

pantoprazole Protonix 40mg tab PO daily

Adult: PO 40mg daily x 8-16wks

Pt. is diagnosed with GERD.

Suppresses gastric acid secretion by inhibiting the proton H+ pump in the parietal cells.

Chest pain, peripheral edema, dizziness, headache, diarrhea, nausea, decreased HDL levels and platelet count, hyperuricemia, increased blood urea nitrogen, dyspnea. Diarrhea, flatulence, abdominal pain, headache, insomnia, and rash.

Monitor kidney and liver function, thyroid function, CBC, serum electrolytes, weight, and total cholesterol. Monitor diabetics for loss of glycemic control. Monitor serum K+ for hypokalemia. Monitor for S&S of Cushings Syndrome. Monitor BP and HR closely for S&S of bradyccardia and HF. Monitor diabetics for loss of glycemic control. Monitor for respiratory status.

Monitor for S&S of angioedema or severe skin reaction.

sertraline HCl Zoloft SSRI 50mg tab PO daily simvastatin Zocor antilipemic 80mg tab PO HS

Adult: PO 50mg/d gradually increase within range of 50200mg/d

Pt. has mild depression.

Inhibits serotonin reuptake in the brain controlling depression, OCD, anxiety, and panic disorder.

Agitation, insomnia, headache, dizziness.

Adult: PO 5-40mg daily max=80mg/d

Pt. diagnosed with severe hyperlipidemia.

More potent than Lovastatin. Decreases serum triglycerides. Decreases LDL, and modestly increases HDL.

Angina, dizziness, headache, fatigue, insomnia, N&V, diarrhea, abd. pain, constipation, flatulence, elevation in CPK.

azithromycin Zithromax antibiotic 500mg vial in NaCl 0.9% 250ml bag @ 250ml/h ceftriaxone Rocephin antibiotic 1gm in NaCl 0.9% 50ml bag @ 100ml/h

Adult Bacterial Infection: IV 500mg daily for at least 2 days.

Pt. is diagnosed with baceterial pneumonia.

Inhibits bacterial protein synthesis.

Headache, dizziness, N&V, diarrhea, abd. pain, hepatotoxicity, mild elevation in liver function tests.

Monitor for worsening depression or suicidal ideation. Monitor older adults for fluid imbalances. PT/INR in pt.s receiving warfarin therapy. Assess and report unexplained muscle pain, and determine CPK level @ onset of pain. Monitor cholesterol levels throughout therapy. Monitor coagulation studies in pt.s receiving warfarin therapy. Monitor for loose stools or diarrhea and rule out psuedomembranous colitis. Monitor PT/INR with warfarin therapy.

Adult: IV 1-2gm Q12-24h x 4-14d (max=4g/d)

Pt. is diagnosed with bacterial pneumonia.

Inhibit bacterial cell wall synthesis, thus killing the bacterium.

Fever, chills, phlebitis @ IV site, diarrhea, pseudomembranous colitis.

acetaminophen Tylenol antipyretic; nonnarcotic analgesic 325mg tab (2 tabs;650mg) PO Q4H PRN

Adult: PO 325650mg Q4-6h (max: 4g/d)

Pt. complains of pain due to R rotator cuff injury.

Provides analgesia by unknown mechanism but reduces fever by direct action on the hypothalamus with consequent vasodilation, sweating, and dissipation of heat.

Hepatotoxicity, hepatic coma, acute renal failure, thrombocytopenic purpura, hepatotoxicity in alcoholics.

Determine hx of hypersensitivity reactions to cephalosporins and penicillins and other allergies. Culture and sensitivity before initiation of therapy. PT/INR should be monitored. Monitor for S&S of hepatotoxicity, do not excced 4g/24h.

Dextrose 50ml syr IV PRN BS<60 Dose: 25ml

Depends on use, age, weight, and clinical condition of pt.

hydrocodone/ acetaminophen Norco narcotic analgesic (opiate) 7.5/325 tab PO Q4h PRN insulin aspart Novolog antidiabetic angent; rapid acting insulin 300 Units/3ml SC sliding scale PRN

Adult: 5-10mg hydrocodone (max: 15mg/dose) 325mg acetaminophen (max dose of acetaminophen not to exceed 4g/24h) Adult: SC 0.250.7units/kg/d injected 5-10 minutes before each meal.

Pt. is diagnosed with diabetes mellitus type 2 and is at risk for insulin induced hypoglycemia. Pt. complains of severe pain due to R rotator cuff injury.

Restores blood glucose levels.

Morphine derivative with greater analgesia than codeine. CNS depressant with moderate to severe relief of pain.

Rare but include alkalosis, acidosis, febrile reactions, fluid overload, hyperglycemia, mental confusion, hypokalemia and hypersensitivity reactions. Constipation, nausea, drowsiness, respiratory depression.

Use cautiously in pt.s with severe kidney damage. Monitor for S&S of thomosis and hyperglycemia. Monitor serum electrolytes esp. K+ Monitor blood glucose levels. Monitor for effectiveness of pain relief. Monitor respiratory status and bowel elimination. Monitor for N&V.

Pt. is diagnosed with diabetes.

More rapidly absorbed than human insulin with more rapid onset and shorter duration than regular insulin.

Hypoglycemia, hypokalemia.

Monitor for S&S of hypoglycemia; initial hypoglycemic response begins within 15 min and peaks 45-90 min after injection. Monitor HbA1C. Withhold med and contact physician if pt. is hypokalemic.

E. Current Orders Orders 2D Echo

12 Lead ECG

CBC daily BMP in the am

Rationale The echocardiogram provides information about abnormalities of the valves, chamber sizes and contents, ventricular muscle and septal motion and thickness, pericardial sac and ascending aorta. The ejection fraction can also be measured with an echo. This information is necessary for diagnostic purposes as well as determining proper treatment (Lewis, 2007 pg 757). Electrocardiogram measures the PQRS complex and is used to assess cardiac function. This diagnostic tool helps identify conduction abnormalities, dysrhythmias, cardiac hypertrophy, pericarditis, site and extent of MI, pacemaker performance, and effectiveness of drug therapy. Because the pt. is diagnosed with atrial fibrillation it is important to gain baseline data to compare future results (Lewis, 2007 pg 756-757). Pt. is taking Solu-Medrol, an immunosuppressant, with concurrent bacterial infection. The pt.s WBC count should be monitored closely for signs of progressing infection. Baseline data on labs such as; glucose, calcium, sodium, potassium, CO2, Chloride, BUN, and Creatinine are used to assess and monitor fluid and electrolyte status, kidney function, blood sugar levels, and responses to medications and therapies. This information is vital to treat any patient but this pt. is diabetic and has severe kidney impairment so it is especially crucial to closely monitor her BMP status. Creatine phosphokinase MB could indicate myocardial cell damage and death. It would be important in a cardiac patient to monitor this enzyme in order to detect tissue necrosis or tissue damage in the case of an MI. Troponins are proteins that are more specific for cardiac muscle injury and differentiate between cardiac and noncardiac chest pain and to diagnose AMI (Kee, 2010 pg 406). Until MI is ruled out, heparin therapy is initiated to prevent thrombus formation (Lewis, 2007 pg 800,803). MI ruled out via cardiac markers, ECG, and Echo. Pt. presented with SOB and weakness accompanied by fever. A chest x-ray will depict cardiac contours, heart size, anatomical changes, enlargement, pericardial effusion and pulmonary congestion. It will also assess the respiratory system and detect pleural effeusion and inflammation (Lewis, 2007 pg 561, 756). Insurance purposes. Pt. is diabetic and upon admission had a blood sugar of 535. Infection and fever may have left the pt. dehydrated and isotonic solution replaces intravascular fluid (Ackley, 2008 pg 372). IV fluid replacement stopped after 1L so not to cause fluid volume overload in the pt.

CPK-MB & Troponin now and in the am start heparin per protocol DC heparin Chest x-ray

Change to inpatient status Stat glucose Accucheck=535 50ml/NS 1L then stop Fe+, B10, folate

Stool for blood x3 Clean catch urine Chest CT Obtain sputum culture

Pt. has GERD which may cause gastrointestinal bleeding. A clean catch urine collection is necessary for UA. CT scans of the chest are used to evaluate areas that are difficult to access by conventional x-ray such as the pleura (Lewis, 2007 pg 526).

Renal profile (BUN & creatinine) Renal panel daily Strict I&O UA with micro Urine with Na+ Sign off with cardiologist; will visit PRN

Pt. is diagnosed with renal insufficiency grade 4. Renal function should be monitored daily to detect worsening kidney impairment and renal failure. Pt. has renal insufficiency and monitoring her intake and output closely will identify changes in renal function. Pt. has renal insufficiency and a urine analysis will identify the kidneys ability to filter and concentrate urine.

Pt. has significant cardiac problems including atrial fibrillation and combined with other concurrent disease processes it is important for the pt. to be assessed by a cardiologist as needed.

F. Laboratory and Diagnostic Tests Student: Brittany Bonner Test Name Normal Range & Reference Units iron 28-170mcg/dL WBC 5-10.2x103/L RBC 3.9-4.9x1012/L Hgb 11.4-14g/dL HCT 34.7-42% Indicate if results are , or within normal limits (WNL). Date Patient Results Date Patient Results Date Patient Results Date Patient Results Date Patient Results Date Patient Results Date Patient Results Date Patient Results Date Patient Results 3/9 3/10 20L 3/10 14.1H 3/10 3.29L 3/10 9.6L 3/10 28L 3/11

Clinical Dates: 3/11/2011 Identify trends in results and rationale for trends. List nursing implications for all significant labs. iron-due to RBC. Pt. received IV iron. Assess pt. for further S&S of anemia and iron deficiency. WBC-pneumonia. Trend is going . Pt. on IV antibiotics. Assess for S&S of progressing infection and respiratory status. Monitor WBC count as labs are available(Kee, 2010 pg 435-436). RBC- possible anemia. Trend is going . Pt. is on corticosteroids. Monitor iron, B12, and folic acid and give supplements as ordered. Hgb-decreased RBCs lowers available Hgb for O2 binding. Monitor pt.s oxygen saturation and Hgb lab values & iron as available. HCT-decreased RBCs lowers RBC concentation. Monitor for S&S of anemia and HCT levels as available.

3/9 12.3H 3/9 3.5L 3/9 10.1L 3/9 29.5L

3/11 7.6WNL 3/11 3.09L 3/11 9.1L 3/11 26.4L

neutrophils 53.4-64.2% lymphocytes 27-31.8% monocytes 3.6-11.2% glucose 70-100mg/dL

3/9 78.6H 3/9 14.7L 3/9 5.3 WNL 3/9 111

3/10 92.5H 3/10 6.7L 3/10 0.7L 3/10 419

3/11 92.9H 3/11 4.6L 3/11 2.4L 3/11 242

neutrophils-acute infection. Trend is going . Pt. is receiving IV antibiotics. Assess pt. for S&S of infection. Monitor WBC and differential(Kee, 2010 pg 437-439). lymphocytes-decrease with steroid therapy and pt. is taking corticosteroids. Trend is going . Assess carefully for S&S of infection because pt.s immune response is suppressed. Monitor WBC counts(Kee, 2010 pg 437-439). monocytes- immunosuppressant therapy. Trend is goind. Monitor closely for S&S of infection and monitor WBC counts (Kee, 2010 pg 437-439). glucose- diabetic, infection, steroid use. Fluctuating trend. Monitor blood glucose with frequent accuchecks. Monitor for S&S of hypoglycemia and hyperglycemia. Administer insulin as ordered and on appropriate sliding scale (Kee, 2010 pg 204-206).

10

BUN 8-26mg/dL Creatinine 0.4-1mg/dL CO2 22-32mmol/L Na+ 136-144mmol/L K+ 3.5-5.3mmol/L

Date Patient Results Date Patient Results Date Patient Results Date Patient Results Date Patient Results Date Patient Results Date Patient Results Date Patient Results Date Patient Results

3/9 55H 3/9 3.58H 3/9 24 WNL 3/9 133 WNL 3/9 4.7 WNL 3/9

3/10 69H 3/10 3.66H 3/10 17L 3/10

3/11 70H 3/11 3.03H 3/11 18L 3/11 126L 3/11

BUN- renal insufficiency and antibiotic use. Trend is going . Monitor urinary output. Report output < 25ml/h (Kee, 2010 pg 86). Creatinine-renal insufficiency, hypertension, and antibiotic use. Trend is going . Monitor I&O. BUN+creatinine=kidney disease (Kee, 2010 pg 149150). CO2- acute renal failure and antibiotics. Trend is going . Assess for S&S of metabolic acidosis i.e. Kussmauls breathing and flushed skin (Kee, 2010 pg 106-108). Na+- renal insufficiency. Trend is going . Assess for S&S of hyponatremia. Monitor urine specific gravity. Monitor vitals. Compare to serum level to urine sodium level (Kee, 2010 pg 385-386). WNL. Continue to monitor.

3/10

Ca2+ 8.9-10.3mg/dL

3/10

3/11 8.6L

albumin 3.5-4.8gm/dL globulin 2.3-3.5gm/dL CPK 38-234 IU/L

3/9 2.8L 3/9 3.9H 3/9 32L

3/10 2.5L 3/10 3.8H 3/10

3/11 2.6L 3/11

Ca2+- renal failure and insulin. Insufficient data to evaluate trend. Observe for S&S of hypocalcemia. Assess for Chvosteks and Trousseaus signs. Administer calcium supplement. Monitor electrocardiogram for dysrhythmais (Kee, 2010 pg 96-98). albumin-renal disorders. Trend is stable. Assess for peripheral edema and acites. Assess skin integrity (Kee, 2010 pg 17-18). globulin- protein deficiency, anemia. Trend going . Assess serum protein and albumin/globulin ratio. CPK WNL. Trend is going . Continue to monitor (Kee, 2010 pg 148).

3/11 49 WNL

11

CK MB 0.6-6.3ng/mL Troponin 0-0.5ng/mL TSH 0.34-5.6 IU/mL

Date Patient Results Date Patient Results Date Patient Results

3/9

3/9

3/9

3/10 2.4 WNL 3/10 0.01 WNL 3/10

3/11 4.1 WNL 3/11 0.02 WNL 3/11 0.79 WNL

WNL. Continue to monitor.

WNL. Continue to monitor.

WNL. Partial thyroidectomy. Continue to monitor.

12

G. Analysis and Diagnoses (10 points) Subjective Data 3/6/11 Pt. stated feeling worse with a fever of 101o F, cough with minimal yellow sputum, and increasing SOB. 3/7/11 Pt. stated temp. was 99.8oF and felt weaker. Pt. c/o pain in right shoulder. Upon admission rated pain @ a 7 on a 010 scale. Objective Data 3/9/11 O2 saturation in physicians office was 88%. Pt. is obese. Baseline labs: creatinine 2.7; Bun 51; GFR of 12; Na+ 133; K+ 4.7; platelet count 239,000; WBC 12.3; Hgb 10.1; Hct 29.5 NSR. Iron, RBC, Hgb and HCT low; WBC count high. Glucose of high. BUN and creatinine high. Chest CT revealed pleural fluid accumulation and atelectasis in right lung. Lung sounds diminished with crakles over right lung base. Respiratory rate of 20 @ rest. Unproductive cough. Fatigue with activity. Pt. displayed signs of pain when bathing right upper extremity and decreased ROM in RUE. Nursing Diagnosis Impaired Gas Exchange r/t pulmonary inflammation, pleural fluid accumulation and mild atelectasis in right lung. AEB: O2 saturation of 88% upon admission, SOB, respiratory rate of 20 @ rest, and fatigue. Risk for Unstable Blood Glucose r/t corticosteroid use. AEB: BS of 535 on 3/9/11, 419 on 33/10/11, and 344 on 3/11/11. Pain r/t right rotator cuff injury (result of recent fall). AEB: Pt. rates pain @ 7 on a scale of 0-10, decreased ROM in right extremity, and facial grimacing while bathing right extremity. Ineffective Airway Clearance r/t pulmonary inflammation and increased secretions. AEB: diminished lung sounds with crackles, unproductive cough, and fluid accumulation in right lung on chest x-ray. Risk for Constipation r/t opioid analgesic use. AEB: last BM 2 days ago, difficulty eliminating for stool sample, and hx of IBS. Impaired Urinary Elimination r/t renal insufficiency. AEB: elevated BUN & creatinine, low urinary output, and decreased serum Na+. Priority 3 Dx 1. Ineffective Airway Clearance r/t pulmonary inflammation and increased secretions. AEB: diminished lung sounds with crackles, unproductive cough, and fluid accumulation in right lung on chest x-ray and CT. Rationale: Patent airway is always priority. It is the most essential physical need. 2. Impaired Gas Exchange r/t pulmonary inflammation, pleural fluid accumulation and mild atelectasis in right lung. AEB: O2 saturation of 88% upon admission, SOB, respiratory rate of 20 @ rest, and fatigue. Rationale: Breathing and O2 perfusion is a critical physical need and must be maintained. 3. Pain r/t right rotator cuff injury (result of recent fall). AEB: Pt. rates pain @ 7 on a scale of 0-10, decreased ROM in right upper extremity, and facial grimacing while bathing right extremity. Rationale: Pain is the 5th vital sign and it can impair several physiological functions including; proper respirations, activity, sleep, and concentration. Pain must be managed to promote healing.

13

H. Plan of Care Student: Brittany Bonner Prioritized Nursing Diagnoses 1. Ineffective Airway Clearance r/t pulmonary inflammation and increased secretions. AEB: diminished lung sounds with crackles, unproductive cough, and fluid accumulation in right lung on chest x-ray and CT. Pts Initials: PG Nursing Action/Intervention Encourage pt. to TCDB and use of incentive spirometry every 2 hours. Assist pt. with position changes and ambulation, keep HOB elevated 45o, and encourage fluid intake. Clinical Dates: 3/11/11 Rationale The TCDB technique can help increase sputum clearance and decrease cough spasms. Incentive spirometry is an effective tool to prevent atelectasis and retention of secretions (Ackley, 2008 pg 125-126) An upright position allows for maximal lung expansion and body movement helps mobilize secretions (Ackley, 2008 pg 125-126) Increased respiratory rate, use of accessory muscles, nasal flaring, and abdominal breathing are signs of hypoxia. The presence of crackles and wheezes may alert the nurse to airway obstruction, which may exacerbate existing hypoxia (Ackley, 2008 pg 388). O2 therapy increased oxygen concentration in each breath leading to increased O2 exchange and tissue perfusion and reverse hypoxemia (Ackley, 2008 pg 126). Systematic ongoing assessment and documentation provide direction for the pain treatment plan and adjustments are made based on the pt.s response (Ackley, 2008 pg 604) Opioid analgesics are indicated for the treatment of moderate to severe pain (Ackley, 2008 pg 605)

2. Impaired Gas Exchange r/t pulmonary inflammation, pleural fluid accumulation and mild atelectasis in right lung. AEB: O2 saturation of 88% upon admission, SOB, respiratory rate of 20 @ rest, and fatigue.

Monitor pt.s respiratory status: auscultate lung sounds, assess rate, depth, and effort of respirations, and monitor O2 saturation every 4 hours. Administer O2 therapy via nasal cannula as ordered: O2 <92%.

3. Pain r/t right rotator cuff injury (result of recent fall). AEB: Pt. rates pain @ 7 on a scale of 0-10, decreased ROM in right extremity, and facial grimacing while bathing right extremity.

Assess pain every 4 hours and establish a comfort function goal with the pt. Administer prescribed Norco PO every 4 hours PRN and reassess pain within 3045 minutes after administration.

Outcomes 1. Pt. will remain@ 95% O2 saturation on RA and will remain free of respiratory distress by 3/11/11. 2. Pt. will demonstrate effective coughing and clear lung sounds by 3/12/11. 3. Pt. will use pain rating scale to identify current pain and maintain a level of pain below comfort function goal by 3/11/11.

Evaluation 1. Goal partially met: Pt. remained @ 95% O2 saturation on RA, but O2 saturation would drop to 92 with activity or ambulation. Pt. became fatigued easily but displayed no signs of respiratory distress. B.Bonner SN, IUK 3/11/11 2. Goal partially met: Pt. displayed clear but diminished lung sounds and was unable to achieve a productive cough for sputum culture. B. Bonner SN, IUK 3/11/11 3. Goal met: Pt. identified a 3 on the pain rating scale as an acceptable level of pain and every 4 hours patient reevaluated her pain to be @ a 2 or less. B.Bonner SN, IUK 3/11/11

APA style Reference page (5 pts.) with an explanation of how the two (2) current research articles were utilized in the plan of care.

14

15

Indiana University School of Nursing Care Plan Assessment Student name: Brittany Bonner Client Initials: PG Age: 77 Date of Care: 3/11/11 Diagnoses: Pneumonia

Cognitive/Perceptual/Communication/Interaction Level of Consciousness: Alert Lethargic Semicomatose Stuporous Comatose General Appearance: Grooming/hygiene_______________________ Manner of dress_____________________ Behavior: Appropriate to situation Combative Confused Anxious Restless Withdrawn Other Describe variance:_________________________________________________ Oriented to: Person Place Time Describe: ______________________________________________________________________ Thought Content: Appropriate to Situation Delusions Obsessions Somatic Concerns Depersonalization Compulsions Paranoia/Suspiciousness Hallucinations Describe variance:______________________________________________________________________ Thought Process: Logical Sequential Relevant Goal Directed Follows Commands Disjointed Irrelevant Tangential Circumstantial Describe variance: _____________________________________________________________________ Memory: Short-term Memory Intact Long-term Memory Intact Memory Not Intact Describe variance:________________________________________________________________ Speech: Clear Slurred Stutter Difficult to Understand Laryngectomy Other Aphasia: Type: ____________________________________ Describe variance:________________________________________________________________ Pupil Reaction: PERRLA (pupils equal, round, and reactive to light and accommodation) Right: Left: Size (circle) 1 2 3 4 5 mm Size (circle) 1 2 3 4 5 mm Brisk Sluggish NR Other _________ Brisk Sluggish NR Other ________ Describe variance: _________________________________________________________________ Eyesight: Normal Other: ____________________________________________________________ Hearing: Normal Other: ____________________________________________________________ Neurological: MAE (Moves All Extremities) Seizures_____________ Headaches _____________ Motor Disturbances (R/L, extremities) __________________________________________________ Sensory Disturbances (R/L, extremities) ________________________________________________ Muscle Strength/tone (R/L, extremities) _________________________________________________ Other:________________________________________________________________ Pain: None Location:)____________________ Rating (1 to 10):_____ (2nd Assess) _________________________

16

Pain Description: Constant Intermittent Aching Burning Cramping Stabbing Dull Throbbing Heavy Crushing Sharp Other _______________________ Describe variance:________________________________________________________________________

Activity/Exercise Respiratory: No Cough Cough Non-productive Productive Sputum (color, characteristics, amount): _________________________________________________________________________ Dyspnea: At Rest With Exertion Orthopnea: # of pillows used:____________ Requires HOB elevated _______ Tachypnea Pursed lip breathing Breathing Pattern: Non-labored Labored Symmetrical Asymmetrical Periods of Apnea Describe variance:___________________________________________________________________ Oxygen delivery mode: Room Air NC Mask (type) _____________________ Pulse Oximetry: On Room Air _____% (result) O2 delivery ___________________ Sat_____% Breath Sounds: Clear/Equal Bilaterally Rate _________ (1st Assess) R L Location (2nd Assess) R L Location Crackles _______________ Crackles _______________ Rhonchi _______________ Rhonchi _______________ Wheezes _______________ Wheezes _______________ Diminished _______________ Diminished _______________ Absent _______________ Absent _______________ Other - Describe variance:__________________________________________________________ _________________________________________________________________________________ Tracheostomy: NA Describe: ________________________Chest Tube NA Describe:___________________________ Pulse Rate: Apical_____ Radial R or L ______ Blood Pressure _______________ site _________ (2nd Assess) Apical_____ Radial R or L ______ Blood Pressure _______________ site _________ Heart Rhythm: Regular Irregular - Describe:_________________________________________ Chest Pain ________________________________________________ Heart Sounds: Audible S1 S2 EKG Rhythm: _____________________________________ (per chart) None in chart, none performed Pacemaker Type: ____________________ AICD Implanted defibrillator ____________________ Describe variance:_____________________________________________________________________ Pulses (0) Absent (1+) Weak, thready (2+) Normal (3+) Full, bounding (D) Doppler Carotid: Right ____ Left ____ Femoral Right ____ Left ____ Brachial: Right ____ Left ____ Popliteal: Right ____ Left ____ Radial: Right ____ Left ____ Post Tibial: Right ____ Left ____ Dorsal Pedis: Right ____ Left ____ Skin Turgor Elastic Tenting____ Capillary Refill: __________________ (# of seconds)

17

Skin: WNL Variances in color/temp/moisture/wounds/rashes/bruising/scars Head & face ________________________ RUE_____________________ LUE_________________________ Torso front & back ____________________ RLE_____________________ LLE _________________________

Edema: None Scale: +1 (2 mm) +2 (4mm) +3 (6mm) +4 (8mm) Generalized (Anasarca) Ascites Dependent Pitting JVD:__________________ Location:_______________________________________________________________________________ Activities of Daily Living: (I) Independent (A) Assist (D) Dependent ___Feeding ___Bathing ___Grooming ___Toileting ___Dressing Other ____________________ Describe variance:________________________________________________________________________ Mobility: Ambulatory Ambulatory w/assistance Transfer w/assistance Bed rest Posture/gait/assistive devices/other variances_________________________________________________ Activity Tolerance: No Problem DOE Weakness Fatigue Dizziness Light-headed Describe variance:________________________________________________________________________ Up ad lib Up in room only Distance walked ______________ SCDs TED hose

Nutrition/Metabolic/Elimination Height: ________ (in/cm) Weight: ______ (lbs/kg) IBW:______________ (lbs/kg)

General Appearance: Well-nourished Obese Thin Cachectic Other____________________ Recent Weight: No Change Loss Gain Intentional - How much?___________(lbs/kg) Over what amount of time?_____________________________ Describe variance:_______________________________________________________________________ Mouth: Full Dentition Dentures: Upper Lower Partial Lesions Sore Mouth Mucous Membranes/Tongue: Moist Pink Dry Pale Other ___________________________ Describe variance:________________________________________________________________________ Type of diet: __________________________________ % Eaten:______________________ Fluid Restriction: N/A or ____________mL/day Recent changes in Appetite Eating Describe variance_____________________________________ Difficulty chewing/swallowing Describe variance:____________________________________________ GI Tubes: Type: _______________ Suction: ______ Drainage: ______________ Residual Amount:______ Tube feeding: Continuous Formula (type and strength) :______________________ Rate: ___________________

18

TPN: Central Peripheral Rate: ___________ Bolus feeding or nutritional supplement ____________ Abdomen: Soft Non-tender Flat Round Distended Gravid Firm Rigid Describe variance:_______________________________________________________________________ Bowel sounds: X 4 Quads Normal Hyperactive Hypoactive Absent Describe variance:_______________________________________________________________________ Stool: Last BM _________Describe (or ask client to describe (color, characteristics, amount, frequency)_______________________ ______________________________________________________________________________________________ Bladder: Continent Incontinent Frequency Urgency Retention Dribbling Foley Describe variance:________________________________________________________________________ Describe urine or ask client to describe (color, characteristics):_________________________________________________ I & O(your shift): I _____________ O _____________ (Last 24 hrs) I _____________ O _____________ Dialysis: Hemodialysis M/W/F or T/R/S Other Describe _____________________________________ Access Location and type:__________________________________________________________________ Intravenous Access: None #1 Site: IVF (type) __________________ Rate__________ Saline lock

Location/condition: Peripheral ____________ Central (type) _______________ PICC Line _______ Describe variance:________________________________________________________________________ #2 Site: IVF (type) __________________ Rate__________ Saline lock Location/condition: Peripheral ____________ Central (type) _______________ PICC Line _______ Describe variance:________________________________________________________________________ Sleep: # of hours: _________ Rested Does not feel rested after sleep Difficulty falling asleep Difficulty staying asleep Naps Usual Sleep Pattern:_______________________________________________________________________ Other - Describe variance:________________________________________________________________

Sexuality/Reproduction Female Breast appearance any variance ___________________________________________________ Vaginal discharge describe color, consistency, odor, amount, frequency ________________________________________________________________________________ Male Penis/scrotum any variance ___________________________________________________

19

Narrative Nurses Note for your time of care:

20

NURSING HISTORY Health Patterns Assessment I.Health Perception/Health Management Pattern a.How has your general health been? Are you presently taking any medication on a regular basis? Indicate name, frequency and dosages of medications. Do you have any allergies? How is the reaction manifested? b.What surgeries have you had in the past? What past and/or present medical conditions do you have? c.What things keep you healthy? (include family folk remedies, etc.) What is your consumption of alcohol, drugs, tobacco per day/week? Do you do self-breast exam or self-testicular exam? d.In the past, has it been easy to follow the suggestions of doctors and nurses? What is the reason for this hospitalization? (indicate medical diagnosis) When did you first notice the symptoms? Provide detailed description of symptoms and their clinical manifestations, client's chief concern. Location, character or quality, quantity or severity, timing (onset, duration, frequency) setting, aggravating or religious factors, associated factors, clients perception of what the symptoms mean. e.What things are important to you while you're here? How can we be most helpful? f.Family health history (i.e., TB, heart disease, hypertension, diabetes, cancer, epilepsy, neurological disorders, congenital anomalies, mental illness and mental retardation.) If appropriate, cause of death of immediate family members. g.Age and present state of health of immediate family members. Problems from Health Perception/Health Management Pattern Current meds include: clonidine, insulin, nifedipine, zocor, Zoloft, protonix, bystolic, and advair @ home. NKA. Partial thyroidectomy. Diabetes, hypertension, renal insufficiency, high cholesterol, asthma, COPD, a-fib. Pt. does not smoke or drink. Pt. stated on 3/6/11 she had a fever and wasnt feeling well so she saw her primary physician in the office on 3/9/11 and was then admitted to the hospital with SOB and fatigue. Pt. states family hx of diabetes and cancer. Husband is deceased, pt. has two living daughters, ages 47, 45, that are in good health. II. Nutritional/Metabolic Pattern a.Describe your typical daily food intake (what and when), include snacks. Do you take vitamins and/or supplements? b.Describe your typical daily fluid intake (what and when). Do you need any assistance? c.Has your appetite changed lately? How would you describe your attitude about food? d.Do you have any special nutritional needs, intolerances, preferences or restrictions we need to be aware of? (include religious, ethnic, and medical) e.Do you need any assistance with oral hygiene? f.Special skin care needs? Problems from Nutritional/Metabolic Pattern Pt states she usually only eats one large meal per day because she lives alone. Usually takes multivitamin. Pt. drinks coffee and tea throughout the day. Pt. reports no change in appetite. Pt. is diabetic.

III. Elimination Pattern a.Bowel Elimination 1.How would you describe your bowel pattern? Include frequency, character and/or discomfort. When was your last BM? 2.Do you have any problems as evidenced by changes, flatulence, diarrhea, constipation, tarry or bloody stools? 3.Do you use aids to assist with elimination? (i.e., enemas, laxatives or others) 4.Is the mode of elimination normal or altered? (i.e., colostomy, etc.) b.Urinary Elimination

21

1.How would you describe your urination pattern? Include frequency, character, and/or discomfort. Does the patient experience dysuria, hematuria, nocturia, burning or incontinence? Describe your observations of client's urinary output. 2. Is the mode of urinary elimination normal or altered? (i.e., foley, urostomy) Problems from Elimination Pattern Pt. has IBS, and states has frequent bouts of diarrhea with some periods of constipation. Pt. states she does not used laxatives or enemas but occasionally takes stool softeners. Pt. states no discomfort with urination.

IV.Activity/Exercise Pattern a.Do you have sufficient energy for your daily activities? Does that include all the things you'd like to do? b.Do you engage in a scheduled exercise program or activity? What kind and how often a week do you exercise? c.What do you like to do with your leisure time? d.Patient's perceived ability for the following (rate ADLs using these functional codes): Level 0 = full self-care Level 1 = requires use of equipment or device Level 2 = requires assistance or supervision from another person Level 3 = requires both equipment and assistance/supervision Level 4 = is dependent and does not participate 0: feeding 2: bathing 0: toileting 2: bed mobility 2: home maintenance 2: dressing 0: grooming 2: general mobility 3: cooking 3: shopping

e.Place patient in Maslow's Hierarchy of Human Needs: physiological and safety. Problems from Activity/Exercise Pattern Pt. states feeling fatigued and SOB with daily activities. Pt. states she does not regularly exercise due to right rotator cuff injury and fatigue. Pt. states she watches television or reads in her leisure time.

V.Sleep/Rest Pattern a.What is your usual sleep pattern? Indicate when, how much, and include any naps. b.Do you believe you get a sufficient amount of sleep? Do you generally feel well-rested? c.Do you ever experience any problems such as dreams, nightmares, or early awakenings that inhibit your sleep? Do you use sleep aids? (medications prescribed or OTC as well as other techniques) d.Would you describe yourself as a "sound" or "light" sleeper? Problems from Sleep/Rest Pattern Pt. states sleep has been better with the use of the Bpap. Pt. has sleep apnea. Pt. usually sleeps 7-8 hours per night with an occasional nap throughout the day. VI.Cognitive/Perceptual Pattern and Neurological Manifestations a.How would you describe your education? Is there anything about your education you would change if you had the opportunity to do so? b.What is the easiest way for you to learn new things? Do you have any difficulty learning? Describe the patient's readiness and motivation to learn. c.Have you had any difficulty with your memory? d.Do you have any difficulty with your hearing? Are there any aids used?

22

e.Do you have any difficulty with your vision? Do you wear glasses/contacts? Are you nearsighted (myopia) or farsighted (hyperopia)? When was your last eye exam? f.Do you have any difficulty with talking or being understood? g.Are you having any pain or discomfort now? When you do have the pain, how would you describe it? Indicate: duration, location (be specific), characteristics (sharp, dull, radiating, burning/gnawing, piercing, cramping or throbbing), degree of pain (use 1-10), precipitating factors (position, exercise, food, anxiety, and any others), relieving factors (diversion, cold, warmth, food, repositioning, rest, analgesics, others). h.Assessment of the reliability of client as an accurate historian: Does the chart validate the client's reported information? Problems from Cognitive/Perceptual Pattern and Neurological Manifestations Pt. likes to read and finds it easy to learn new things by reading. Pt. states no problems with memory, but claims to be a little hard of hearing but no hearing aids are used. Pt. wears reading glasses. Pt. states no pain. Pt. is reliable and accurate.

VII.Self-Perception/Self-Concept Pattern a.How would you describe yourself? Do you feel good or not so good about yourself most of the time? b.Do you see any changes in your body that need to be made? What kind of things can you do to achieve this? Will this be a problem for you? c.Do you see yourself as ill? Do you believe this illness has changed you and/or your body? d.Do you find that things frequently make you angry? Annoyed? Fearful? Anxious? Depressed? What seems to help? How can we help? Problems from Self-Perception/Self-Concept Pattern Pt. states feeling happy but concerned about her illness. She states that she is anxious about getting better and going home. Pt. takes Zoloft for mild depression and anxiety. VIII.Role/Relationship Pattern a.Do you live alone? Family? Diagram of family structure - optional. What kind of housing do you live in? Do you consider this adequate for your needs now and after hospitalization? b.What kind of work do you (did you) do? How long have you been (were you) employed? Have you enjoyed your employment? c.Are there any family problems you have difficulty handling? d.Does the family depend on you for much? How will they manage while you are here? Will this be difficult for you? e.How does your family feel about your illness/hospitalization? f.Do you anticipate problems with children? Will this be difficult to handle? g.Do you belong to any social groups? Do you have any close friends? Do you ever feel lonely? How often? h.Do things generally go well for you at work (school)? Problems from Role/Relationship Pattern Pt. states that she has lived alone in her home since her husband past away. Pt. is was a homemaker and is not employed. Pt. stated she has been a little depressed after losing her husband, but gets support from her two daughters, and says that the Zoloft is helping her. IX.Sexuality/Reproductive Pattern a.At what age did menstruation begin? When was your last menstrual period? Have you had any changes or difficulties in your cycle? b.Gravida (pregnancies)? Para (births)? What contraceptives and/or birth control? c.Do you believe this illness/hospitalization will affect your sexuality?

23

Problems from Sexuality/Reproductive Pattern Pt. stated menstruation began @ approximately 13 years of age and she is postmenopausal. Gravida 2, para 2. X.Coping/Stress Tolerance Pattern a.Have you experienced any big changes in your life during the last year or two? b.Would you ever describe yourself as "tense"? What seems to help? Medicines? Drugs? Alcohol? Tobacco? c.Who is the most helpful to you when you need to talk things over? Is that person available to you now? d.When you have big problems in your life, how do you handle them? e.Does this help most of the time? f.Assess client's growth and development according to Erikson and Maslow. Is this stage appropriate for client's age? Problems from Coping/Stress Tolerance Pattern Pt. states she is mostly calm and happy. Pt. stated she is close with her daughters and talks with them frequently and they help her cope and deal with problems. Pt. claimed that this is usually helpful. Pt. is ready for the self-actualization stage of Maslow and the integrity vs despair of Erikson. XI.Value/Belief Pattern a.Is religion important in your life? What is your church affiliation? b.Does this help when difficulties arise? c.What religious beliefs do you have that might affect your health care? d.What ethnic/cultural beliefs do you have that might affect your health care? e.What do you value most in life? Problems from Value/Belief Pattern Pt. states she is Christian and belongs to a Baptist church but that she does not attend regularly. Pt. states that she finds comfort when she prays or reads the Bible. Pt. states that she values family most in life.

24

Grade Sheet for Formal Care Plan Criteria A. Pathophysiology: 10 points Able to discuss the top 3 diagnosis, as applicable, with signs and symptoms B. Summary of Hospitalization 4 points Discusses the patients course of hospitalization C. Disease relationship Able to identify actual disease relationship and how they relate to each other D. Medications: Completes all requirements for medication ( name, side effects, nursing implications E. Current Orders: 10 points Does a review of orders with rationale. Identifies potential problems ( if any) in orders F. Lab Values 10 points Identifies abnormal lab values and trends. States rationale and nursing implications. Note: may group similar issues such as a low HGB and low RBC G. Analysis/ Diagnosis 10 points Able to organize assessed data into issues. Identifies top three nursing issues H. Plan of Care 24 points Develops top three issues into plan of care. Includes at least two (2) research articles related to current practice and discusses utilization in Care Plan Reference page includes APA reference for research articles Total 2 points Possible points Comments

10 points

5 points 85 points

25