Nursing Care Plan Med/Surg Student Name :

Nursing Care Plan Med/Surg Student Name : KATY LOVE Date of Care 10/1/2022 Demographics Room # ICU 10 BED Gender MALE Age 65 Code Status FULL Allergies NKA Day of Admission 9/28/2022 Diet NPO Activity BED RIDDEN Emergency Department Presentation/Chief Complaint -ALTERED LEVEL OF CONSCIOUSNESS, CONFUSION, TACHYPNEA & TACHYCARDIA Primary Diagnosis on Admission – ACUTE RESPIRATORY FAILURE BILATERAL PNEUMONIA Medical History -HYPERTENSION, OBTRUCTIVE SLEEP APNEA, DM2, DEPRESSION, HYPERLIPIDEMIA, LEFT HIP OSTEOMYELITIS, ATTENTION DEFICIT DISORDER, PNEUMONIA Surgical History -PERCUTANEOUS ENDOSCOPIC GASTROSTOMY; FLEXIBLE FEEDING TUBE PLACED THROUGH THE ABDOMINAL WALL AND INTO THE STOMACH. THIS ALLOWS NUTRITION, FLUIDS AND OR MEDICATION TO BE PUT DIRECTLY INTO THE STOMACH BY PASSING THE MOUTH AND ESOPHAGUS Primary problem on day of care (if different than diagnosis) -RESPIRATORY CHANGES Pathophysiology of Primary diagnosis (cite) -THIS DISORDER OCCURS WHEN THE LUNGS ARE NO LONGER MET IN THE BODY’S METABOLIC NEEDS. RESPIRATORY FAILURE IS A MEDICAL EMERGENCY, OFTEN THE FINAL STAGE OF CHRONIC LUNG DISEASE. THIS CAN RESULT FROM SEVERE, SUDDEN LUNG DISEASE (SUCH AS ACUTE RESPIRATORY DISTRESS SYNDROME) IN OTHERWISE HEALTHY PEOPLE. AN OVERDOSE OF OPIODS OR ALCOHOL CAN CAUSE SEDATION THAT A PERSON STOPS BREATHING AND SUFFERS RESPIRATORY FAILURE. OBSTRUCTION OF THE AIRWAYS, INJURY TO THE LUNG TISSUES, DAMAGES TO THE BONES AND TISSUES AROUND THE LUNGS, AND WEAKNESS OF THE MUSCLES THAT USUALLY INFLATE THE LUNGS ARE ALSO COMMON CAUSES. RESPIRATORY FAILURE CAN OCCUR IF BLOOD FLOW THROUGH THE LUNGS BECOME ABNORMAL, AS HAPPENS IN PULMONARY EMBOLISM. THIS DISORDER DOES NOT STOP AIR FROM MOVING IN AND OUT OF THE LUNGS, BUT WITHOUT BLOOD FLOW TO A PORTION OF THE LUNGS, OXYGEN IS NOT PROPERLY REMOVED FROM THE AIR. PATIENTS WILL CHRONICALLY HIGH CARBON DIOXIDE LEVELS, EXCESS OXYGEN CAN RESULT IN SLOWING OF THE MOVEMENT AIR (VENTILATION) IN AND OUT OF THE LUNGS WHICH INCREASES THE CARBON DIOXIDE LEVEL. THE UNDERLYING CAUSE OF THE RESPIRATORY FAILURE MUST ALSO BE TREATED. ANTIBIOTICS ARE USED TO FIGHT INFECTION AND BRONCHODIALATORS ARE USED TO OPEN AIRWAYS. OTHER DRUGS MAYBE GIVEN TO DECREASE INFLAMMATION OR PREVENT BLOOD CLOTS. SOME VERY ILL PATIENTS MAY NEED FOR MECHANICAL VENTILATION TO AID BREATHING. THIS CAN BE LIFESAVING WHENEVER PEOPLE ARE NOT ABLE TO MOVE ENOUGH AIR IN AND OUT OF THE LUNGS. A PLASTIC TUBE IS INSERTED THROUGH THE NOSE OR INTO THE TRACHEA; THIS TUBE IS TO ATTACHED TO A MACHINE THAT FORCES AIR INTO THE LUNGS. EXHALATION OCCURS PASSIVELY BECAUSE OF THE ELASTIC RECOIL OF THE LUNGS. -GREENE, K.E., & PETERS, J.I (1994). PATHOPHYSIOLOGY OF ACUTE RESPIRATORY FAILURE. CLINICS IN CHEST MEDICINE, 15(1), 1-12. HTTPS://PUBMED.NCBI.NLM.NIH.GOV/8200186/ Admission summary (HPI) Verbatim -65 YEAR OLD MALE WAS FOUND ALTERED LEVEL OF CONSCIOUSNESS AND CONFUSED AT HOME PER WIFE. P.T WAS ADMITTED TO ER DX WITH RESPIRATORY FAILURE BILATERAL PNEUMONIA, TREATED WITH IV ANTIBIOTICS. Course of Hospitalization – THE P.T IS A 65 YEAR OLD MALE WITH A HISTORY OF HTN, OBSTRUCTIVE SLEEP APNEA, DM2, DEPRESSION, HYPERLIPIDEMIA, LT HIP OSTEOMYELITIS, A.D.D, PNEUMONIA. WIFE FOUND P.T ON THE FLOOR AT THE HOUSE WITH ALOC ALONG WITH CONFUSION. P.T WAS BROUGHT FROM HOME VIA AMBULANCE ACCOMPANIED BY HIS WIFE “MARIA”. P.T IS FULL CODE STATUS WITH NKA TO MEDICATIONS. ADMISSION DX OF RESPIRATORY FAILURE BILATERAL PNEUMONIA, TREATED WITH IV ANTIBIOTICS. PLACED ON MECHANICAL VENTILATION, TRACHEOSTOMY, PERCUTANEOUS ENDOSCOPIC GASTROSTOMY PLACEMENT WITH A FOLEY CATHETER AND RUNNING IV FLUIDS OF SODIUM CHLORIDE 0.9% ON LT UPPER ARM. MRI OF THE BRAIN SHOWED NO ABNORMALITY & CXR IS PENDING FOR RESULT. LAB RESULTS ARE IMPROVING. HE IS ROUTINELY BEING MONITORED FOR HTN, OSA, DM2, HYPERLIPIDEMIA. P.T IS FEEDING ON TWOCAL HN G/TUBE/PEG AT 45 ML/HR RATE. ATTENDING DR. PLANS IS TO HAVE NEPHRO, CARDIO, PSYCHIATRIC, P.T & O.T CONSULT. Vital Signs Time 0740 1100 1345 Temp 99.3 99.0 99.1[nl3] P 70 77 78 RR 18 18 17 BP 143/89 146/92 141/93 O2 sat 93% 96% 94% O2 delivery method & flow rate. VENT; RATE=16 VENT TIDAL=600ML FI02=30% PEEP=7 VENT; RATE=16 VENT TIDAL=600ML FI02=30% PEEP=7 VENT; RATE=16 VENT TIDAL=600ML FI02=30% PEEP=7[nl4] Pain NONE; SEDATED NONE; SEDATED NONE; SEDATED Pain location NONE; SEDATED ONE; SEDATED NONE; SEDATED Intake Output Enteral N/A Urine 300 ML; VIA FOLEY CATH Oral N/A Chest Tube N/A PEG Tube TWOCAL HN; 45ML/ HR Parenteral N/A Drains Other N/A Other N/A Total Total 300 ML Relevant Provider Orders Listed in Priority for Day of Care (minimum of 3) Order Rationale ELEVATING HOB EXPANSION OF LUNG CAPACITY AND PREVENTAIVE OF ASPIRATION MONITOR 02 SAT PERFUSION OF THE BODY MEASURING BP PREVENTATIVE OF SHOCK LAB/BSG CHECK DM 2 ASSESSING LUNG SOUND EVERY HR MONITORING FURTHER RESPIRATORY ABNORMALITIES REPOSITIONING EVERY 2 HRS PREVENTING REDNESS, SKIN BREAKDOWN AND ULCERS Holistic Care Primary Language -ENGLISH Family System -MARRIED, 3 KIDS Religion -MORMOM; IS A CULTURE PRACTICE BASED CHURCH OF DOCTRINE OF LAWS OF HEALTH, PARTICIPATION OF LEADERSHIP OF THE CHURCH, REFRAINING FROM WORK ON SUNDAYS, FAMILY HOME EVENINGS, MINISTERING TO OTHER CHURCH MEMBERS, BELIEVES IN THE CRUCIFIXION, RESURRECTION AND DIVINITY OF JESUS OF CHRIST. Socio-Cultural Factors -HIGH SCHOOL EDUCATION, FORMER LIMOUSINE OWNER, RETIRED Environmental Factors -LIVES IN A TWO-STORY HOUSE WITH WIFE, DAUGHTER AND SON IN LAW WITH 2 DOGS Erikson’s Developmental Stage -INTEGRITY VS. DESPAIR; PATIENT IN THIS STAGE EITHER FEEL GOOD ABOUT THEMSELVES THAT THEY HAVE REACHED THEIR GOALS IN LIFE RESULTING THAT LIFE HAS A MEANING TO IT OR THEY ARE DISSATISFIELD AND FEEL AS IF THEY HAVE MISSED THE OPPORTUNITIES AND FALL INTO DESPAIR, REFLECTS ON ONES LIFE TIME LINE AND FACE LIFE’S END. Patterns of Living at Home -LIVES IN IRVINE WITH WIFE AND DAUGHTER AND SON IN LAW. HELPS CARE FOR 2 YOUNG GRAND KIDS Healthcare Insurance -MEDICAL IEHP Assessment Data Ht/Wt/BMI 74 INCHES/ 245 LBS/ 31.5 BMI Behavior CALM AND COMFORTABLE HEENT NORMOCEPHALIC, EARS INTACT, NO CONJUNCTIVITIS OR JAUNDICE, NOSE INTACT, THROAT ALONG MIDLINE Neurological SEDATED Cardiovascular SINUS NORMAL, +3 NORMAL PULSES, EQUAL RATE & RHYTHM, CAPILLARY REFILL <3 SECS, NO SIGNS OF EDEMA Respiratory SYMMETRIC EXPANSION, BREATHING SOUNDS DECREASED AT BASES GI SOFT, NORMOACTIVE BOWEL SOUNDS PRESENTED GU FOLEY CATH IN PLACE DRAINING YELLOW TO CLEAR URINE Musculoskeletal BED REST, BILATERAL LEGS COMPRESSION SLEEVES IN PLACE , MUSCLE WEAKNESS, UNABLE TO ASSESS GAIT DUE TO SEDATION Skin NO SWELLING OR EDEMA SPICES (for a geriatric patient) S-UNABLE TO ASSESS SLEEP PATTERN DUE TO SEDATION P-CURRENTLY ON TUBE FEEDING; TWOCAL HN (((CALORIE AND PROTEIN DENSE NUTRITION-SUPPORTING PATIENT WITH VOLUME INTOLERANCE AND OR FLUID RESTRICTION))); 45ML/ HR I-FOLEY CATH IN PLACE; CLEAR TO YELLOW URINE C-CURRENTLY SEDATED E -NO SIGNS OF REDNESS OR OPEN WOUNDS Pain NO SIGNS OR FACIAL APPEARANCE OF PAIN DUE TO SEDATION IV Site LT UPPER FOREARM, 22G P.IV, PATENT, NO SWELLING & REDNESS AT SITE Braden Risk Assessment Scale Points Description Intervention for area of risk Sensory/Mental 1 COMPLETELY LIMITED ASSESS LOC OF STIMULI EVERY HR OF SHIFT Moisture 3 OCCASIONALLY MOIST GENTLY CLEANSE SKIN FOLDS & PERINEAL AREA & PAT DRY Activity 1 BED FAST REPOSITION PATIENT EVERY 1-2 HOUR OF SHIFT Mobility 1 COMPLETELY IMMOBILE ELEVATE HEAD OF BED NO MORE THAN 30 DEGREE Nutrition 3 ADEQUATE ACT QUICKLY TO ALLEVIATE WHEN DEFICIT OCCURS Friction/Shear 1 PROBLEM KEEP BED LINENS AND LAYERS UNDER THE P.T SMOOTH & WRINKLE FREE Total & Risk 10 SEVERE RISK Morse Fall Scale Points Description Intervention for area of risk History of falls 0 NONE NONE 2nd diagnosis 15 PNEUMONIA 2ND DX, SLIP PROOF SOCKS, MATS ON FLOOR, ALL RAILS UP Ambulatory aid 0 NONE NONE IV/saline lock 20 LT UPPER FOREARM SLIP PROOF SOCKS, MATS ON FLOOR, ALL RAILS UP Gait/Transfer 20 SEDATED SLIP PROOF SOCKS, MATS ON FLOOR, ALL RAILS UP Mental status 15 SEDATED SLIP PROOF SOCKS, MATS ON FLOOR, ALL RAILS UP Total & Risk 50 HIGH RISK Labs (Related to Current Medical Diagnosis with Attention to Trends and Abnormal) Lab Value Normal Range Prior Day of Care Trend Rationale and/or action for abnormal value Date WBC 5,000-10,000 9.7 RBC N/A Hgb Male: 14-18g/100 ML 12.2 ? Hct Male: 42-52% 36.8 Patelets 150,000-400,000 321 Neutrophil bands % N/A Neutr/segs % N/A PT N/A PTT N/A INR N/A Chemistry Na 137-145 138 K 3.6-5.0 3.9 Cl 98-107 102 BUN 7-20 23 ? Cr 0.6-1.3 1.0 Gluc ose 74-100 104 Ca 9.2 8.4-10.2 Mg 1.3-2.1 2.3 ? Phosphate 3.0 -4.5 4.4 Albumin N/A Total protein N/A HgA1c N/A Liver/Pancreas ALT N/A AST N/A Ammonia N/A Bilirubin N/A Amylase N/A Lipase N/A Cardiac Troponin N/A BNP N/A CK N/A CRP N/A Point of Care Testing [nl8] Time Test Value Rationale and/or action for abnormal value 9AM BS 99 REGULAR INSULIN; >150-200= 3 UNITS >201-250= 6UNITS >251-300= 9 UNITS CALL MD >300 Urine/fecal Date Results Urinalysis N/A Fecal/Occult blood N/A Microbiology Culture (state source) 9/28/22 COVID; NEGATIVE Diagnostic Test Chest x-ray 9/28/22 PENDNING EKG 9/28/22 NSR CT/MRI 9/29/22 NORMAL Medications Administration Record ***I COULD NOT LOCATE WHAT SEDATION DRIP THE PATIENT IS ON IN THE MAR** Scheduled Medication TIME DOSE/ROUTE Pharm or Thera. class REASON Major SIDE EFFECTS Nursing Implications DOXAZOSIN QD 2 MG/G TUBE ALPHA BLOCKER HTN, BPH HEADACHEM DIZZINESS, HYPOTENSION, WEAKNESS, FATIGUE, TACHYCARDIA Monitor BP and pulse 2-6 hr after first dose, with each increase in dose, and periodically during therapy. Report significant changes. WELLBUTRIN QD 75 MG/G TUBE NOREPINEPHRINE & DOPAMINE REUPTAKE INHIBITOR ANTIDEPRESSANT HEADACHE, DIZZINESS, DRY MOUTH, CONSTIPATION, SORE THROAT, INSOMNIA MONITOR SUCIDAL IDEATION/ SUCIDAL. ADMIN WITH FOOD MINIMIZE GI ISSUES, ASSESS PHYSICAL CONDITIONS, HALLUCINATIONS, DELUSIONS ENOXAPARIN QD 40 MG/ G TUBE ANTICOAGULANTS PREVENTS BLOOD CLOTS BLEEDING GUMS, COUGHING BLOOD, HEADACHE, NOSEBLEEDS, SOB, DIFF SWALLOWING, PROLONG BLEEDING FROM CUTS EDUCATE P.T IF EXCESSIVE BLEEDING OR BRUSING OCCURS ANYWHERE IN THE BODY OCCURS, OR DOES NOT STOP WITH PRESSURE APPLIED FOR FULL 2 MINS LOSARTAN QD 25 MG/ G TUBE ANTIHYPERTENSIVE HTN BLURRY VISION, N/V SOB, DIZZINESS, FAINTNESS, NUMBNESS OR TINGLING ON HANDS, FEET, LIPS, STOMACH DISCOMFORT ASSESS FOR ANGIOEDEMA, BP, PULSE DOCUSATE SODIUM QD 200 MG/ G TUBE LAXATIVE STOOL SOFTNER STOMACH PAIN, DIARRHEA, CRAMPING, IRRITATED THROAT ASSESS CRAMPING, N/V, EDUCATE P.T DO NOT CHEW MEDS IN STEAD SWALLOW LASIX QD 20 MG/ G TUBE DIURETIC RID OF WATER DEHYDRATION, ELECTROLYTE IMBLANCE, CONFUSION, DIZZINESS, IRREGULAR HR, N/V MONITOR ELECTROLYTE LABS, DYSRRHYTMIAS, MONITOR P.T WHO HAS DM, MONITOR BP FREQ REGULAR INSULIN QD 3 UNITS SHORT ACTING INSULIN DM2 SWEATING, DIZZINESS, SHAKINESS, HUNGER, BLURRED VISION, FAST HR ROTATE INJ SITE, MONITOR HYPOGLYCEMIA, REMEMBER THE 3P’S (POLYURIA, POLYDIPSIA, POLYPHAGIA), DOUBLE CHECK ORDER CYCLOBENZAPRINE QD 10 MG/G TUBE MUSCLE RELAXOR MUSCLE SPASM UNSTEADINESS, CLUMSINESS, MENTAL DEPRESSION, PRBLM URINATING, YELLOW IN SCLERA, RINGING IN EAR ADMIN WITH FOOD TO AVOID GI ISSUES, DO NOT CHEW OR CRUSH MEDS DIAZEPAM QD 5 MG/ G TUBE BENZODIAZEPINES ANXIETY, DEPRESSION, SEIZURE DROWSINESS, TIREDNESS, DIZZINESS, HEADACHE, NAUSEATED, CONSTIPATION ELDERLY=MONITOR CNS HYPERACTIVE, DEPRESSION, MONITOR DRUG INTERACTION, MOTHERS=BREAST FEEDING LYRICA QD 150 MG/ G TUBE ANTICONVULSANT, FIBROMYALGIA NERVE DAMAGE DRY MOUTH, TREMOR, DOUBLE VISION, HYPOTENSION,EUPHORIA, TWITCHING MONITOR BEHAVIOR CHANGES, DEPRESSION, ASESSS LOCATION, DURATION, & INTENSITY PAIN, CAN CAUSE DECREASE PLT LVELS HYDROCODONE QD 325 MG/G TUBE ANALGESIC PAIN BLADDER PAIN, DIFF OR LABOR PAIN, FEAR OR NERVOUSNESS, HEADACHE, RUNNY OR STUFFY NOSE, SORE THROAT, TIREDNESS, WEAKNESS TAKE AS PRESCRIBED, DO NOT DRINK ALCOHOL AND DRIVE, DO NOT STOP OR ABRUPT MEDICATION CARVEDILOL QD 25 MG/ G TUBE BETA ADRENERGIC BLOCKING AGENT HTN, HEART FAILURE ALLERGY, CHEST PAIN, DISCOMFORT, TIGHTNESS, HEAVINESS, WEIGHTGAIN, SLOW HR MONITOR BP, I & O, WEIGHT DAILY ATORVASTATIN QD 20 MG/ G TUBE HMG COA REDUCTASE INHIBITOR CHOLESTROL DIARRHEA, HEARTBURN, GAS, JOINT PAIN, CONFUSION, MEMORY LOSS, FORGETFULNESS MONITOR DM P.T GLUCOSE LEVEL, OBTAIN DIET HISTORY PRN Medication Freq DOSE/ROUTE Pharm or Thera. class REASON Major SIDE EFFECTS Nursing ImpliFOR TARcations HALOPERIDOL PRN 5MG/ G TUBE ANTIPSYHOTIC DELIRIUM DRY MOUTH, INCREASE SALIVA, BLURRED VISION, LOSS APPETITE, DIARRHEA, HEARTBURN USE CATIOUS W P.T THAT HAS CARDIAC & ELECTROLYTE ISSUES. MONITOR FOR TARDIVE DYSKINESA, BCB, EPECIALLY LOW WBC TYLENOL PRN 650 MG/ G TUBE ANALGESIC MILD PAIN N/V, STOMACH PAIN, RASH, DARK URINE, CLAY COLORED STOOL, LOSS OF APPETITE, ITCHINESS MONITOR TOXCITY, LVEL OF PAIN, EDUCATE P.T AND FAMILY ADVERSE EFFECT OF THE MEDICATION, MONITOR FOR SEDATION AND RESPIRATORY SEDATION OPT LUBRICANT PRN OINTMENT LUBRICATION DRY EYES ITCHINESS, REDNESS, HIVES EDUCATE FOR ALLERGY REACTIONS IV Fluids Time DOSE/ROUTE REASON Major SIDE EFFECTS Nursing Implications SODIUM CHLORIDE 0.9% 250ML/ IV ELECTROLYTE REPLENISHER SWELLING ANKLES, FEET HANDS, MUSCLE CRAMPS, HEADACHE, NAUSEA, SEIZURES, DROWSINESS ASSESS PATENCY, REDNESS, WARMTH, INFILTRATED , DISCHARGE Discharge Planning Prior to admission: Independent/Partial or Totals assistance needed? -INDEPENDENT Would you recommend any services post discharge & why? -HOME HEALTH NURSE=ASSESS AND EDUCATE FAMILY OF TRACH CARE, G TUBE CARE, P.T=RESTORING BACK TO FULL STRENGTH, IMPROVING MOBILITY, O.T=IMPROVING PHYSICAL SKILLS P.T NEEDS TO & WANT TO DO IN THEIR LIVES Who will care for you after discharge?-WIFE & DAUGHTER Who will drive you when you leave the hospital? -DAUGHTER What is your current living arrangement? -LIVES IN IRVINE, CALIFORNIA WITH FAMILY What is the anticipated discharge date? -UNABLE TO DETERMINE What is the anticipated destination & why?-FAMILY HOME Home Skilled Nursing Facility Rehab Other Are there any physical challenges at home?- STAIRS; PLACING SAFETY BARS AND IN THE RESTROOM AS WELL (stairs, rugs, ramp, safety? Discharge motivational Level?-UNABLE TO DETERMINE Critical Thinking 1. What is your patient’s primary diagnosis or problem for the day? – ACUTE RESPIRATORY FAILURE BILATERAL PNEUMONIA 2. What are the important assessments to make? -ASSESS RATE, RHYTHM, RESPIRATION, ACCESSORY MUSCLES -ASSESS EFFECTIVENESS OF COUGHING -ASCULTATE LUNG FIELD SOUNDS -MONITOR 02 SATS -ELEVATE HOB -REPOSITIONING P.T EVERY 2 HRS -VENTILATOR SETTING; -REVIEW CXR RESULTS -REVIEW ABG RESULTS 3. How is your patient trending? E.G. Vital signs, Labs, Focused assessments etc. – 4. What could go wrong with your patient today? -PERMANENT DAMAGE OR SCARRING TO THE LUNGS, LEADING TO INFECTION=SEPSIS, HEART DAMAGE, NEURO COMPLICATION=LACK OF 02, KIDNEY DAMAGE 5. How might you prevent/intervene with your patient if this occurs? -MONITORING VS, O2, JVD, AUSCULATATE LUNG & HEART SOUNDS, ASSESS LOC, RESTLESSNESS, PROMOTE HAND HYGIENE, OBSERVE EKG AND CHANGES WITHIN THE EKG, 6. What orders might you expect the physician to order if this problem were to occur? -CXR, CT SCAN, ABG, ELECTROCARDIOGRAM, ECHOCARDIOGRAM, LAB WORK, MRI Nursing Diagnosis: 3 NANDAs[nl14] Place in order of priority (2 ACTUAL & 1 RISK) 1. 2. 3. NANDA Subjective / Objective Data and subjective Goal/Expected Outcome (appropriate and measurable) Nursing Interventions and Rationales Evaluation of Patient Response 1. 1. 1a 1. Subjective: 1b. Objective: 1c. 2. 1. 1a. 1. Subjective: 1b. Objective 1c 3. 1. 1a. 1. Subjective: 1b Objective: 1c -PATHO OF PRIMARY DX PLEASE LET ME KNOW IF I SHOULD ADD ADDITIONAL INFO -COURSE OF HOSPITALIZATION MY PROFESSOR STATED THIS SECTION I DID WAS INCORRECT. IF YOU WERE THE STUDENT NURSE THAT DAY WITH THIS PATIENT, WHAT WOULD YOU HAVE DONE THAT DAY FOR THIS PATIENT. EXAMPLE: THE TEMP WAS SLIGHTLY ELEVATED, THERE WERE ALSO ELEVATED LAB WORK AS WELL -ON THE DAY OF THE CARE, I DO NOT REMEMBER THE PATIENT NURSE DID NOT SUGGEST ANYTHING ABOUT IT OTHER THAN MONITERING IT EVERY 15 MINS, NO MEDS WERE GIVEN I DO NOT RECALL PATIENT HAVE 02 USAGE, SHOULD I MAKE IT UP STATING P.T USED NASAL CANNULA AT 5L/MIN? -POSSIBLE REASONING THE LAB WORK LEVEL IS LOW/HIGH? -POINT OF CARE ANYTHING I CAN ADD ADDITIONAL TO THIS SECTION? -MEDICATION ANY SUGGESTION OF WHAT SEDATION DRIP I CAN ADD TO THE LIST, I COULDN’T LOCATE SEDATION MEDS IN THE P.TS MAR -What is your patient’s primary diagnosis or problem for the day? MY PROFESSOR STATED, I DID THAT INCORRECTLY, WHAT WOULD BE A BETTER CHOICE? -How is your patient trending? E.G. Vital signs, Labs, Focused assessments etc THE LABS WERE IMPROVING, WBC AND HGB LEVELS ARE DECREASEING HEART DAMAGE, HOW? KIDNEY DAMAGE HOW? -What orders might you expect the physician to order if this problem were to occur? -CXR, CT SCAN, ABG, ELECTROCARDIOGRAM, ECHOCARDIOGRAM, LAB WORK, MRI[nl1] HOW AND WHY ARE THESE DONE? -PLEASE HELPS WITH 3 NURSING DIAGNOSIS THANK YOU!! SCIENCE HEALTH SCIENCE NURSING NURSING 764

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