Student Name: Heddy Cortijo

Date Submitted: 8/2/15

Admit
Risk for Falls and skin breakdown
History of Present Illness

Code status: FULL

Medical Dx: Right Knee Arthritis - ESRD
Surgical Procedure and date:
Right knee total replacement 7/28
Past Medical Hx:
ESRD
Subclavian steal syndrome, right arm
Hypertension
Carotid stenosis Right
Hyperlipidemia

Age: 63
Female
Cultural: Filipino
Spiritual: Catholic
Marital Status: Married
Occupation: Housekeeper
Living condition: in house with
husband and family

Interdisciplinary referrals (state one

appropriate referral with rationale)

Allergies:
Bactrim- facial swelling
Cipro- GI upset
Spironolactone- GI upset
Sulfa- swelling
Metoprolol- rash, itching

General appearance and behavior:

1. Affect: appropriate for current situation. Congruent with thought content.
2. Mood: appropriate for current situation, very relaxed and friendly.
3. Thought Process: coherent. Follows logical thought process.
4. Thought Content: Appropriate content.
5. Cognitive Evaluation: appropriate. ST and LT memory WNL for age. Oriented x4
6. Insight: adequate understanding of current situation,
7. Judgment: able to come to appropriate conclusions
8. Level of Function: functioning at an appropriate level
9. Psychiatric status: no current psychiatric diagnoses or signs of
10. Psychotropic Medications: none currently
Type of IV solution & Rate:
Psychosocial assessment:
Lactated Ringer 100ml/hr
1.Housing: lives in house with husband and several other relatives.
Type of IV Access & Location:
2. Transport: Husband drives patient around.
PIV Right antecubital
3. Financial: works as housekeeper, disability.
4. Support: Family, big family.
5. Follow-up
List all IV medications (research compatibility &
Diagnostic tests including test results (pre- and postinfusion rate for each med.)
procedures nsg. implications later in CIS)
Knee X-ray 7/28 status post total knee replacement. Alignment
Med./dose
Time
Infusion rate Compat.

Treatment: (include PT, OT, precautions)

Glucose check before breakfast and dinner
Incentive spirometry q1h while awake
Flowtron compression devices
VS (q15min x2, q30min x2, q1h x2, q4h x48h, then
q8h and PRN)
Neuro check (q4h x8h, then q8h and PRN)
OOB-TID
WBAT
Hemovac Right knee
Surgical wound Right knee- abdominal dressing
with ted hose- NO CHANGE needed
Discharge Planning (write one or two of patient's discharge
needs or summarize case management's notes regarding
discharge)

Type of Diet: regular

Fluid Restriction:
Enc. Fluids:

Activity (ability to walk - gait): WBAT, walks on own

Type of activity:
Use of assistive device:
Weight/height: 62.3kg/157.5cm
Elimination (continent/incontinent): continent
Foley/condom cath/ st. cath: voiding
Last BM (constipation):
**For insulin: needs to state the peak and duration; also indicate short-acting, rapid acting or intermediate-acting or longacting.
**May tab drug book for clinical days; when turn in your written work on Sat, needs to complete all columns listed below:
List all p.o. & s.c., newly ordered & prns Meds
Ordered
Time
Mechanism of
Med/dose/frequency
action
(what is the usual dose
and frequency for this
med.)
Amlodipine 10mg PO
0900
Calcium channel
daily
blocker
Selectively blocks
calcium influx across
membrane of cardiac
and vascular smooth
muscle
Ascorbic Acid (Vitamin c) 0900
Vitamin
500mg PO BID daily
2100
supplement, urinary
acidifier
Increases protective
mechanism immune
system thus
increasing wound
healing and infection
prevention
Atorvastatin 80mg PO
0900
Antilipidemic, HMGdaily
COA, statin
An inhibitor of HMGCoA, an essential
enzyme for hepatic
production of
cholesterol.
Increases the
number of hepatic
LDL receptors thus
increasing uptake of
LDL.

Indication
(how is this
med relate to
your pt.s
condition)
HTN

Major Side effects

Boost immune
system

Heartburn, headache,
urethristis, dysuria,
abdominal cramps,
dizziness, hemolytic
anemia, sickle cell
crisis

Monitor H/H and

electrolytes

Hyperlipidemia

Confusion, diarrhea,
pain, nausea, muscle
spasms

Monitor labs (lipids)

Do not break tab
Same time daily
Assess for muscle
pain, tenderness,
weakness
Monitor glycemic
control

Docusate sodium 100mg

BID PO
Enoxaparin 40mg subq
q24h

0900
2100
0600

Stool softener

Constipation

Anticoagulant, low
molecular weight
heparin

Bedrest, prevent
DVT

Ferrous sulfate 324mg

PO BID with meals

Breakfas
t

Iron supplement,
antianemic

Anemic

Peripheral or facial
edema, headache,
syncope, arthralgia,
cramps, fatigue

Nsg. Implications
(what
preparations do
you need prior to
administration)
Monitor BP
Change position
slowly
Monitor HR
Monitor for edema

Bloating, diarrhea

No mineral oil

Hemorrhage,
thrombocytopenia,
angioedema, anemia,
fever, urticaria
Nausea, heartburn,
anorexia, constipation,

Watch for
unexplained
bleeding
Monitor platelet
Monitor BM
Monitor Hgb

Dinner

Correct erythropoietin
abnormalities

Losartan 25mg PO daily

0900

HTN

Dizziness, insomnia,
headache, myalgia,
muscle cramps,
sinsuitis

Nebivolol (bystolic) 5mg

PO daily

0900

Angitensin II
receptor antagonist,
antihypertensive
Vasoconstriction,
RAAS blocks binding
of angiotensin II
Beta-adrenergic
antagonist,
antihypertensive
Blocks beta 1
receptor, high doses
block 1 and 2

HTN

Headache, insomnia,
asthenia, decreased
platelet, increased
BUN, chest pain,
peripheral edema

Monitor HR and BP
Monitor glucose
control
Monitor RR
Monitor Lipoid and
LFT

Non narcotic
analgic, antipyretic
Elevates pain
threshold, inhibits
action of endogenous
pyrogens on the heat
regulating center
Stimulant laxative
Expands intestinal
fluid volume by
increasing epithelial
permeability
Centrally acting
cholinergic
antagonist,
antihistamine, H1receptor antagonist
Blocks histamine
release at H1
receptor
Same as above

Fever/pain

Hepatotoxicity, hepatic
coma, leukopenia,
thrombocytopenia,
purpura, anorexia,
rash, n/v, diarrhea,
epigastric pain

NTE 4g/day
Monitor if on other
meds with
acetaminophen

Constipation

Mild cramping, N/V,

diarrhea, fluid and
electrolyte
disturbances

Itch

Drowsiness, dizziness,
headache,
cardiovascular
collapse, dry nose,
throat, restlessness,
fever, tachycardia, dry
mouth, anaphylaxis

Evaluate continued
use
May decrease
absorption of
vitamin K
Give with food
Monitor cardio
Supervise
ambulation

Saline cathartic,
laxative
Causes osmotic
retention of fluid,
which distends colon
and stimulates
peristalsis
5-HT3 antagonist,
antiemetic
selectively inhibits
serotonin.

Constipation

Antihistamine,
antiemetic,

Nausea/vomiting

PRN
Acetaminophen 325650mg PO q4h

Bisacodyl 10mg sup

rectally daily

Diphenhydramine 25mg
PO q4h

Diphenhydramine 25mg
IM inj q4h
Milk of Mag. 400mg/5ml
15-30ml PO QHS

Ondansetron inj 4mg IV

q4h

Promethazine 12.5mg
IVPB q4h

black stools, liver

necrosis, death

Citrus fruit and

tomato juice
increases
absorption
Dark green/black
stools
Monitor BP
Monitor CBC,
Lytes, liver, kidney

Itch

Nausea/vomiting

N/V, abdominal
cramps, coma,
respiratory depression,
lethargy, dehydration

Headache, dizziness,
sedation, dry mouth,
constipation, lightheadedness,
hypersensitivity.
Leukopenia,
agranulocytosis

Shake first
Monitor F/E

Monitor F/E
Monitor cardio
status
Beware of
headache possible
anaphylaxis
With food, milk, or
full glass of water

antivertigo
Depression of CTZ in
medulla
Promethazine 25 IVPB
q4h
Promethazine 25mg PO
q4h
Fleet Enema 1 bottle
rectally daily

Respiratory
depression, apnea,
sedation, drowsiness,
blurred vision, dry
mouth

Same as above

Nausea/Vomiting

Same as above

Nausea/Vomiting

Stimulant laxative
Expands intestinal
fluid volume by
increasing epithelia
permeability

Constipation

Cramping, nausea,
diarrhea, F/E
disturbances

Monitor F/E

Nursing Diagnosis (complete ONE nursing diagnosis of highest priority for the first day of clinical.(for Thursday) Also include
expected
outcome
and
nursing
interventions.
Nursing RN,
interventions
include
assessment,
interventions
and teaching.
Gulanick,
PhD,
APRN,
FAAN,
M., & Myers,
MSN, J.should
L. (2011).
Nursing
care plans:
Diagnoses,
nd
Complete
the
2
plan
of
care
for
the
second
day
of
clinical
(Friday).
Evaluate
patients
responses
during
clinical.
interventions, and outcomes Missouri: Elsevier Mosby.
#1 Nursing dx:
Lab Test

Normal

Date/ Result

Date/ Result

Date/ Result

Rationale for abnormalities specific

Risk for Decreased Cardiac

Output
r/t of
Fluid imbalances affecting circulating volume, myocardial workload,
andclient
systemic vascular resistance
Range/
Unit
to your
measure
(SVR)
CHEM 25

Glucose,outcome:
fasting
65-100
113
Expected
BUN
6-23
17
Maintain
cardiac output as0.6-1.4
evidenced by BP and0.5
heart rate within patients normal range; peripheral pulses strong and equal with prompt
Creatinine
capillary
refill
time.
BUN/Creatinine
10-20:1
. Sodium
135-145
142
Potassium
3.3
Nursing
Interventions 3.5-5
Patient Responses to interventions
Chloride
98-107
104
1. Auscultate heart and lung sounds. Evaluate presence of
No development of edema, congestion, or dyspnea. Heart and lung
TCO2
23-27
24
peripheral
edema,
vascular
congestion
and
reports
of
dyspnea.
sounds remained clear throughout hospitalization.
Magnesium
1.8-3.0
2. Assess
activity level, response
Was able to increase activity throughout care. Up in chair and toileting
Phosphorus
2.5-4.5 to activity.
Calcium
8.5-10.2
8.3
on her own.
Albumin heart sounds 3.5-5
3. Evaluate
(note friction rub), BP, peripheral
Patient came in with murmur. BP still elevated, being corrected with
Total protein
6.5-8.2
pulses,
capillary
refill,
vascular
congestion,
temperature,
and
medication. Temperature and cap refill WNL.
Globulin
2.3-3.5
sensorium
or
mentation.
A/G ratio
Bilirubin, total
0.3-1pain, noting location, radiation,
4. Investigate
reports of chest
No reports of chest pain throughout care.
Bilirubin,
direct
severity
(010
scale), and<0.4
whether or not it is intensified by
Bilirubin, indirect
deep
inspiration and supine position.
Uric acid
2.5-7.8
Evaluation
of whether
Osmolality
(Calc) outcome(s)
275-299 are met: Met, no signs or symptoms of decreased cardiac output.
CPK
Digoxin Tx
BNP
Troponin I
Troponin T
LDH
AST (SGOT)
ALT (SGPT)
GGTP

0-5
<100
0.6-2.8
<0.1
100-190
<35
10-35
15-80

** Modify normal range according to the hospital standard

Lab Test

Normal
Range/ Unit of
measure

Alkaline
phosphatase,
Amylase
Lipase
Cholesterol

44-147

Triglycerides
Homocysteine
Others:
Lactic Acid
ABG
pH
PaCO2
Pao2
O2 saturation

80-150

HCO3
BE
Urinalysis
Color

21-28
+-3

30-100
<160
<200

3-7
7.35-7.45
35-45
75-105
96-100

Yellow

Date/ Result

Date/ Result

Date/ Result

Rationale for abnormalities specific

to your client

Appearance
Specific gravity
pH
Leukocytes
Nitrites
Protein
Glucose
Ketones
Urobilinogen
Bilirubin
Erythrocytes
UA microscopic
WBC
RBC
Epithelial cells

Clear
1.050-1.030
4.6-8
Neg.
Neg.
50-80
Neg.
<5
1-4
None
2

Occult blood

<3

Bacteria

None

80-100
0-5

Mucus
Casts

None

Crystals

None

Yeast
Comments
Cultures and
sensitivities
Organism
Sensitivity for
ordered antibiotic
Sensitivity for
ordered antibiotic
Sensitivity for
ordered antibiotic
Other tests
Blood culture

Neg.

** Modify normal range according to the hospital standard

After assessment, identify important

physical assessment findings in the
above diagram & below

Clinical Day #1

VS ___99.0, 78, 18, 162/76, 97%____

Neurological/Mental Status
A/O x4 to person, place, time and situation. PERRL 2mm brisk. No sensory deficits in vision, hearing, taste, or
smell, all WNL. No pain with swallowing. Speech clear and easily understandable. No numbness or tingling or
changes in sensation noted. Motor and strength in right lower extremity, all others WNL.
Respiratory System

RRR. No cough or sputum noted. No use of accessory muscles or cyanosis noted. Breath sounds clear by
auscultation in all areas. No history of smoking. Pulse oximeter at 97% on room air. No chest tube
Cardiovascular System
ESRD- 5 stages
All pulses palpable and equal bilaterally. No edema noted. S1, S2 heard clear, Murmur present. No complaints
of chest pain. Cap refill WNL <3 seconds.
Gastrointestinal System
Abdomen soft and non-tender. Last BM prior to hospitalization. Patient unsure of exact date. BS x4 quadrants,
normoactive. No ostomy or NG tube in use.
Musculoskeletal System
No fractures or dislocations noted. Complains of pain to RLE, aching, 3/10, denies pain medication. All pulses
palpable and equal. Decreased ROM to RLE, all others WNL.
Genitourinary System
Patient denies any pain or burning sensation upon urination. Voiding on own, urine amount WNL, yellow, clear.
No Nephrostomy tube noted.
Skin & Wounds
Skin color WNL for race and age. Skin turgor normal. Skin CDI. Periperal IV to Right antecubital, dressing CDI.
Wound to RLE, covered in abdominal dressing and TED hose.

Circle the appropriate assessment if applicable and describe what you observe using medical terminology

Clinical Manifestations:
Electrolyte imbalances, poor water excretion
Hyponatreamia
Hyperkalemia
Kussmaul breathing
GFR >90ml/min
Vitamin kidney,
D deficiency
Normal functioning
no signs of

Hypocalcemia
kdieny disease
Hypertension
Hyperlipidemia
Mild CKD
GFR60-89
Heart
failureml/min. damaged
nephrons,increased
metabolic waste,
Cardiomyopathy
increased output
of dilute urine
Anemia
Halitosis
Moderate CKD--.
GFR 30-59ml/min.
Stomatitis
remainingnephrons
cannot manage build up of
Seizure/coma
metabolicwast
Pericarditis
Increased RR
SOB, pallor, lethargy, weakness, dizziness

Severe CKD GFR 15-29

ESRD GFR<15ml/min
Increased urea and creatinine, build up of
metabolic waste, F/E imbalances, acid-base
imbalances

Medical Treatment:
- Hemodialysis
- Peritoneal dialysis
Surgical Treatment:
Graft/fistula insertion

Nursing Interventions (should be cited from the textbook):

Prevent injury
Prevent infection
Monitor Fluid volume
Prevent pulmonary edema
Increased cardiac output
Monitr GFR
Lifestyle changes:
Vitamin replacement
Sodium restriction

References: Ignatavicius, D and Workman, M.L (2013). Medical-surgical nursing. Patient-centered collaborative

care (7th ed), St Louis, MO: Saunders.