CSU, STANISLAUS B.S.N.

CLINICAL PLAN OF CARE

Student _Stephanie Rebeiro_____ Date of Care __10/24/13_____ Room Number _383__
Patient Data
Admitting Diagnosis _Hypertensive Intracranial bleed__Age _52_ Spiritual Focus_No preference__ Culture_white_
Patient Initials _DB__ Gender _female_ Height _160cm_ Weight _162 kg_ Admitting Date _10/11/13_ POD: _N/A_
Vital Signs: T _98.4 oral_ P _98_ R _24_ B/P _202/104_ O 2 Sat _98% on 2L nasal Cannula_ Pain Scale _0/10_
Past Medical History __hypertension, diabetes, sleep apnea, COPD_________________________
____________________________________________________________________________________________
Surgical History ___N/A_______________________________________________________________________
Diet __diabetic, pureed_____ Activity _bedrest__
Foley ___NO_____ NG/Feeding Tube ____NO_____
Advance Directives:
Yes ________ No __X___
Drains/ Tubes __________________________________
Code Status _DNR___ VS Freq __Q4h_____
Glucose Monitoring _Yes , AC__ TEDs/SCDs _Yes____
Vascular Access:
Yes
PCA/Epidural _____No________ Telemetry _No___
IV Site: _3-lumen PICC R upper arm_ IV Solution: _NS/saline lock_
Safety Considerations _side railsX4, seizure precaution, risk for aspiration, turn pt Q2h__
Dressing Changes ___None___________________
Labs to be drawn __CBC, K, MG__________________
___________________________________________
Scheduled Procedures __N/A___________________
Notes on pathophysiology: Hypertensive intracranial bleed: Hypertensive intracerebral hemorrhage is caused by long-term high blood
pressure. When blood pressure has remained high for a significant period of time, the walls of blood vessels change. Constant, high blood pressure
wears away at the vessel walls and can lead to blockage of the vessels and leakage of blood into the brain. Blood irritates the brain tissues, causing
swelling. The blood collects into a mass called a hematoma. Brain tissue swelling and a hematoma within the brain put increased pressure on the brain
and can eventually destroy it.

Lab and Diagnostic Test Data

1

Test
type(date)

Normal Range

Patient Results

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient care &

teaching
Levels are on the high side. This may be a sign of
failing kidneys which may be due to her untreated
hypertension and diabetes. Monitor patients I&O
and urine for any changes. Continue to monitor
labs.
Pts levels are on the low side. Monitor pts I&O and
urine for any changes. Continue to monitor labs.

BUN

10/11 10/23
6-20mg/dL

15

26

up

Measure of renal
function, glomerular
filtration rate, and
liver function

Creatinine

0.6-1.2 mg/dL

0.6

0.6

sam
e

Calcium

9-10.5 mg/dL

8.8

9.9

up

CO2

23-30 mEq/L

29

35

up

Chloride

98-106 mEq/L

97

98

sam
e

Used to diagnose
impaired renal
function. It is used as
an approximation of
GFR. An increased
level indicates a
lower GFR
Used to evaluate
parathyroid function
and calcium
metabolism
Used to assist in
evaluating the pH
status and assist in
evaluation of
electrolytes
Can give indication of
acid-base balance
and hydration status

AGAP

7-16 mEq/L

13

13

sam
e

Glucose

Fasting:70-110
mg/dL
Normal: >200
mg/dL

212

143

dow
n

Used to test positive

and negative ions in
blood. Cane be a
result of failing
kidneys.
Measures blood
glucose level

Pt is on the lower end, may need supplementation if

continues to drop. Side effect of Lasix. Continue to
monitor for any changes.
Levels are a little high, may be due to pts history of
COPD. Continue to monitor for any changes.
Assess SpO.
Pt was low and now within normal limits. Pt is taking
lasix which will reduce electrolytes. Continue to
monitor for any changes. Electrolytes important for
heart function.
Pt is within normal limits. Will continue to monitor
I&O and urine, any abnormal changes (decrease
output, dark urine) may indicate kidney failure.
Pts levels have dropped since admission, may be
due to treatment with insulin and sliding scale in
hospital. Continue to monitor and assess pt for
increase thirst and urine output as signs of
hyperglycemia. Or sweating weakness, dizziness,
chills and nausea as signs of hypoglycemia. Ensure
diabetic diet.

Test
type(date)

Normal Range

Patient Results

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient care &

teaching

Glucose
POC

Fasting:70-110
mg/dL
Normal: >200
mg/dL

238

162

dow
n

Measures blood
glucose level

3.9

3.2

dow
n

136-145 mEq/L

135

143

up

WBC

4-11

9.4

11.3

up

Evaluated to ensure
cardiac function.
Abnormal potassium
levels can lead to
dysrhythmias.
Evaluate and monitor
fluid and electrolyte
balance
Evaluate presence of
infection

Neutrophil

1.4-6.5

6.7

8.4

up

Evaluate presence of
infection

Basophil

0-0.2

0.1

0.1

Involved in allergic
reactions

Eosinophil

0-0.7

0.2

0.4

Sam
e
up

Pt had high level when admitted. Pt being treated at

hospital with insulin sliding scale. Levels are lower
now. Continue to monitor levels and assess pt for
increase thirst and urine output for hyperglycemia.
Or sweating weakness, dizziness, chills and nausea
as signs of hypoglycemia. Ensure diabetic diet.
Continue to monitor for any changes
Pt levels are low. Side effect of lasix. Continue to
monitor to check if supplementation is needed.
Potassium supplementation is ordered.
Electrolytes important for heart function.
Pt levels have slightly increased. Pt is on lasix which
may lower levels. Continue to monitor for any
changes. Electrolytes important for heart function.
Results are high. Assess temp. and heart rate as
signs of infection. Could be due to fluid in lungs due
to pneumonia or previous UTI. Pt not on any
antibiotics. Ensure peri-area stays clean and dry.
Results are high. Assess temp. and heart rate as
signs of infection. Could be due to fluid in lungs due
to pneumonia or previous UTI. Pt not on any
antibiotics. Ensure peri-area stays clean and dry.
Pt shows no sign of allergic reaction. Continue to
monitor for changes.

Potassium

3.5-5.0 mEq/L

Sodium

Lymphocyte

1.2-3.4

1.7

1.5

dow
n

Monocyte

0-0.8

0.6

0.9

up

Hct

37-47%

43.1

38.7

Dow
n

Involved in allergic
reaction
Evaluated in the
presence of an
infection
Evaluated in the
presence of an
infection
Used as an indirect
measurement of red
blood cell count and
volume

Pt shows no sign of allergic reaction. Continue to

monitor for changes
These counts are low. Continue to monitor results.
Assess pt for increased temp. and HR
These counts are a little above normal. Continue to
monitor results. Assess pt for increased temp. and
HR.
On the low end, pt may be dehydrated due to
honey-thick diet pt didnt like thickened water.
If continues to drop may signify bleeding. Continue
to monitor for any changes. Monitor B/P and HR.

Test
type(date)

Normal Range

Hgb

12-16 g/dL

RBC

4.2-5.4

MCV

Patient Results

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient care &

teaching

15

up

Continue to monitor for any changes

Levels are within normal limits. If continues to drop
may indicate bleeding. Monitor B/P and HR

4.9

4.32

Dow
n

Used as a rapid
indirect measurement
of the red blood cell
count
Evaluates the
number of RBCs in
the peripheral blood

80-98

87.8

89.4

up

MCH

27-32 pg

30.5

30.2

Sam
e

MCHC

32-36%

34.7

33.8

Dow
n

RDW

11-14.5%

14

up

INR

0.8-1.1

0.9

Platelet
Count

130-400/L

253

333

Up

MPV

7.4-10.4 fL

9.3

10.2

up

PT

11.0-12.5 sec.

9.4

13.1

13.7

N/A

N/A

Measurement of red
blood cells. Indicator
of anemia.
help in measuring the
average size and
hemoglobin
composition of the red
blood cells
It denotes the amount
of hemoglobin in a
specific volume of
'packed' red
corpuscles or cells.
Indicator of anemia
Provides information
on red blood cell
distribution width
Blood test for clotting
time
Count of number of
platelets per cubic
milliliter of blood

Used to aid in
diagnosis of
suspected bleeding
disorders
Used to monitor the
extrinsic system and
the common pathway

On the low end, pt may be dehydrated due to

honey-thick diet pt didnt like thickened water.
If continues to drop may signify bleeding. Continue
to monitor for any changes. Monitor B/P and HR.
Continue to monitor for any changes.
Pt is within normal limits. Will assess pt for further
changes such as low SpO2 or cold, cyanotic
extremities. Pt does not appear to be anemic
Continue to monitor for any changes.
Pt is normal. Will assess pt for further changes such
as low SpO2 or cold, cyanotic extremities. Pt does
not appear to be anemic.
Continue to monitor for any changes. Within normal
limits. Will assess pt for further changes such as low
SpO2 or cold, cyanotic extremities. Pt does not
appear to be anemic.
Continue to monitor for any changes. Pt. within
normal limits.
Pt within normal limits. Will continue to monitor for
any changes.
Continue to monitor for any changes. Pt. is on the
low side of normal. Pt. taking heparin. Pt diagnosed
with thrombocytopenia. Many meds she is taking
cause thrombocytopenia.
Continue to monitor for any changes. Within normal
limits.
Slightly below limits. Will continue to monitor. Pt not
receiving lovenox shot due to hemorrhage

Test
type(date)

Normal Range

Patient Results

Trend

PTT

60-70 sec.

25

N/A

Troponin

<0.2 ng/mL

<0.01

N/A

UA
appearance

clear

10/14
cloudy

N/A

UA color

Amber yellow

Yellow

N/A

UA spec
gravity

1.005-1.030

1.010

N/A

UA pH

4.6-8.0

5.0

N/A

UA luek

neg

Neg.

Neg.

N/A

Rationale
(specific to pt.)
of clot formation
Used to monitor the
intrinsic system and
the common pathway
of clot formation. Also
used to monitor
heparin therapy.
Indicator of cardiac
muscle injury,
predictor of possible
future cardiac events
Can reveal info about
kidneys and
metabolic processes.
Routine diagnostic
and screening eval.
Can reveal info about
kidneys and
metabolic processes.
Routine diagnostic
and screening eval.
Can reveal info about
kidneys and
metabolic processes.
Routine diagnostic
and screening eval.
Can reveal info about
kidneys and
metabolic processes.
Routine diagnostic
and screening eval.
Indicates acid-base
balance
Can reveal info about
kidneys and
metabolic processes.
Routine diagnostic
and screening eval.

Nursing Implications related to patient care &

teaching
Pt well below normal. Will continue to monitor.

Pt within normal limits. Will continue to monitor. No

apparent MI
Pt abnormal. Will assess urine for color change
which may indicate kidney failure

Pt normal. Will assess urine for color change which

may indicate kidney failure

Pt within normal limits. Will continue to monitor for

kidney function

Pt within normal limits. Will continue to monitor for

kidney function.

Pt within normal limits. Will continue to monitor for

kidney function.

Test
type(date)

Normal Range

Patient Results

UA nitrite

neg

UA protein

0-8 mg/dL
50-80mg/24 hr
at rest

25

N/A

UA glucose

Random: neg
50-300 mg/24
hr

Norm.

N/A

UA ketones

neg

N/A

UA
urobilinoge
n

0.01-1 Ehrlich
unit/mL

N/A

UA bili

none

N/A

Neg.

Neg.

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient care &

teaching

N/A

Can reveal info about

kidneys and
metabolic processes.
Routine diagnostic
and screening eval.
For identification of
UTIs
Can reveal info about
kidneys and
metabolic processes.
Routine diagnostic
and screening
eval.Indicator of renal
disease.
Can reveal info about
kidneys and
metabolic processes.
Routine diagnostic
and screening eval.
Can reflect a degree
of glucose elevation
in the blood.
Can reveal info about
kidneys and
metabolic processes.
Routine diagnostic
and screening eval.
Usually associated
with diabetes control
Can reveal info about
kidneys and
metabolic processes.
Routine diagnostic
and screening eval.
Can reveal info about
kidneys and
metabolic processes.
Routine diagnostic
and screening eval.

Pt within normal limits. Will continue to monitor for

kidney function.

Pt has fallen below normal. May be due to pureed

diet. Will continue to monitor for kidney function.

Pt. normal will continue to monitor, a high reading

may indicate diabetes

Pt was above limits may be due to uncontrolled

diabetes. Will continue to monitor for diabetes
control.

Pt within normal limits. Will continue to monitor for

kidney function.

Pt above normal limits. Will continue to monitor for

kidney function.

Test
type(date)

Normal Range

Patient Results

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient care &

teaching

UA blood

neg

250

N/A

Pt above normal limits. May be due to CVA and

stress on body. Will continue to monitor for kidney
function.

Bill Total

0.3-1.0 mg/dL

0.7

0.4

dow
n

AST

10-50 units/L

27

21

Dow
n

Albumin

3.5-5.2 g/dL

3.1

3.2

up

ALT

0-41 units/L

40

44

up

ALK Phos

40-129 units/L

78

95

up

Total
Protein

6.4-8.3 g/dL

6.1

6.4

up

Magnesium

1.6-2.6 mEq/L

10/20
2.4

CKMB

0-4.7

4.2

Can reveal info about

kidneys and
metabolic processes.
Routine diagnostic
and screening eval.
Used to evaluate liver
function and evaluate
hemolytic anemias
Used in the
evaluation of patients
with suspected
heptocellular
diseases.
Used to diagnose,
evaluate and monitor
chronic edematous
states. A measure of
hepatic function and
nutrition,
Helps to identify
hepatocellular
diseases of the liver
Used to detect and
monitor diseases of
the liver or bone
Used to diagnose,
evaluate and monitor
impaired nutrition,
liver dysfunction, and
immune disorders
Test is to identify
magnesium
deficiency or
overload
This test is specific to
myocardial cells and
this number will rise
after an infarction. A

10/23
2.2

dow
n
N/A

Continue to monitor for any changes. Any changes

may indicate liver damage, meds will be adjusted
accordingly.
Continue to monitor for any changes. Any changes
may indicate liver damage, meds will be adjusted
accordingly.
Continue to monitor for any changes
This is on the low end which may be due to the diet.
Continue to monitor lab and assess pt for jaundice.

Pt is within normal and slightly above normal.

Continue to monitor for further changes. Monitor pt
for jaundice.
Pts numbers have increased. Continue to monitor.
Pt levels have increased. Continue to monitor.

Patient is within normal limits. May be due to

supplementation. Do not need to supplement.
Continue to monitor, important for heart function.
Will supplement if levels drop. Lasix will drop levels.
This number is within normal limits. No apparent
infarction.

Test
type(date)

Normal Range

Patient Results

Trend

Hgb A1C

<6.5

8.2

7.5

N/A

Phosphate

3.0- 4.5 mg/dL

4.8

4.2

N/A

Cholesterol

110-200

HDL

10/11
256

N/A

40-85

39

N/A

LDL

1-100

143

N/A

Trig lvl

60-175

371

N/A

Rationale
(specific to pt.)
rise may be seen in
pts with shock,
malignant
hyperthermia,
myopathies,
myocarditis
This test shows
diabetes control over
the past 2-4 months
This test is performed
to assist in the
interpretation of
studies investigating
parathyroid and
calcium
abnormalities. Or to
measure phosphate
levels to ensure
adequate blood
levels exist
This test shows the
level of cholesterol in
the blood. High
cholesterol is
associated with AVD
This test shows the
level HDLs in the
blood
This test shows the
levels of LDLs in the
blood. LDLs are most
directly associated
with CHD
This test shows the
levels of triglycerides
in the blood. They
identify the risk of
developing CHD

Nursing Implications related to patient care &

teaching

Pt is high. This shows that she did not take very

good care of her diabetes. The number is slowly
dropping as her diabetes are being taken care of in
the hospital.
Levels are within normal limits. Pt does not appear
to have any parathyroid problems. Continue to
monitor.

Her levels are very high. She has hyperlipidemia

and this is why she is prescribed Simvastatin. High
cholesterol also plays a role in her hypertension
These are the good cholesterol levels, and her
levels are low. A change in diet like eating more nuts
or fish oils may bring up this number.
This is the bad kind of cholesterol. Her number is
very high and is probably due to her diet. She is
prescribed Simvastatin and this should help lower
this number.
Her levels are really high and are probably due to
poor diet. These high levels probably mean that she
has a really high risk of developing CHD

Test
type(date)

Normal Range

VLDL

6-35

Pro BNP

Trend

Rationale
(specific to pt.)

Nursing Implications related to patient care &

teaching

74

N/A

These levels are very high and probably due to a

poor diet. The simvastatin should lower this too

0-124

80

N/A

This test showls the

levels of VLDLs in the
blood
This test is used to
identify and stratify
pts with CHF

CT scan
head
EEG

10/11

Chest x-ray

10/13

Hemorrhage in
rt cerebral area
Brain activity
slightly limited
in rt side
Tube in place

10/11

Patient Results

The pts levels are within normal range so the pt

more tha likely does not have CHF yet

Medication Allergies: ___NKDA____________________________________________

Medications
Generic & Trade Name
Drug classification

dose/Route
Frequency

Action of drug and

Rationale
(specific to Pt)

Significant Side Effects

Nursing Implications related to

patient care and teaching

650 mg = 2
tabs oral
Q6h prn
temp >
38C

May block pain impulses

peripherally that occur in
response to inhibition of
prostaglandin synthesis;
does not possess antiinflammatory properties;
antipyretic action results
from inhibition of
prostaglandins in the
CNS. To be given to pt if
fever occurs

Hepatoxiticity, GI bleeding, renal

failure, leukopenia,
neutropenia,hemolytic anemia,
thrombocytopenia,
pancytopenia, cyanosis, anemia,
CNS stimulation, seizures, coma

Assess or chronic poisoning,

hepatotxicity, teach patient not to
exceed recommended dosage,
not to use with alcohol, to
recognize signs of chronic
overdose

325-7.5mg,
1 tab oral

Acts directly on cough

center in medulla to

Drowsiness, seizures, circulatory

depression, cardiac arrest, N&V,

Assess CNS changes, monitor B/P,

pulse, respirations, if respirations <

(Therapeutic &
Pharmacologic)

Acetaminophen
(Tylenol)
Nonopiod analgesic,
antipyretic
Nonsalicylate,
paraaminphenol derivative
New med.

AcetaminophenHYDROcodone

(Norco)
Antitussive opioid
analgesic/ nonopioid
analgesic
New med.

Amlopidine
(Norvasc)

Q4H prn
mild pain

suppress cough; binds to

opiate receptors in CNS to
reduce pain. For mild to
moderate pain.

anorexia, constipation, respiratory

depression, pulmonary edema,
bronchopneumonia, respiratory
arrest

10mg=1 tab
oral daily

Inibits calcium ion influx

across cell membrane
during cardiac
depolarization;produces
relaxation of coronary
vascular smooth muscle,
peripheral vascular smooth
muscle; dilates coronary
vascular arteries,
increases myocardial O2
delivery in pts with
vasospastic angina. To
treat pts hypertension
Produces alpha 2 agonist
activity seen at low and
moderate doses, also
alpha 1 at high doses. To
calm pt and put in sedative
state.
Completely inhibits
histamine at histamine H2
receptor site, thus
decreasing gastric
secretion while pepsin
remains at a stable level.
Given to prevent ulcers
from intake of new meds.
Inhibits ascending pain
pathways in CNS,
increases pain threshold,
alters pain perception by
binding to opiate receptors.
Inhibits reabsorption of
sodium and chloride at
proximal and distal tubule

Headache, peripheral edema

Antianginal;
antihypertensive, CCB
Dihydropyridine
New med.

Dexmedetomidine
(Precedex)
Sedative, alpha2 adrenoceptor agonist
New med.

Famotidine
(Pepcid)
H2-histamine receptor
antagonist
New med.

Fentanyl
Opioid analgesic
Synthetic phenylpiperidine
New med.

Furosemide
(Lasix)

400mcg
and NS 96
mL, IV

20mg= 2mL
IV push
Q12h

25mcg=0.5
mL IV push
Q4h prn
severe pain
40mg=4mL
inj IV push
Q12h

10/min. dose may need to be

reduced. Teach that physical
dependency may result with
extended use, to change positions
slowly. Have patient eat with food to
prevent N&V
Assess HR and B/P, do not skip or
overdose, to comply in all area of
medical regimen, notify provider of
irregular heartbeat, SOB, swelling
feet, hands, or face, severe
dizziness. Fall risk, orthostatic
hypotension. Ask provider if HR <50.
Photosensitivity may occur.

Bradycardia, hypotension, atrial

fibrillation, infarction, cardiac arrest,
pulmonary edema, pleral effusion,
hypoxia

Contraindicated for chronic

hypertension.
Assesss HR, B/P, EKG, CNS
changes, put up side rails, night light,
call button close.

Headache, dizziness, seizures in

renal disease, disrhythmias, QT
prolongation, Thrombocytopenia,
aplastic anemia, toxic epidermal
necrolysis, Stevens-Johnson
syndrome, pneumonia

Assess CBC and BUN

periodically, drowsiness may
occur, avoid irritating foods

Bradycardia, arrest, respiratory

depression, arrest,
laryngospasm

Assess VS, assess respirations,

CNS changes. Teach to about
coughing, turning, deep
breathing,

Circulatory collapse,
hypokalemia, hypochloremic
alkalosis, hypomagnesemia,

Assess B/P, assess for depleted

electrolytes; increase fluids to 2-3
L/day; encourage high potassium

10

Loop diuretic
Sulfonamide derivative
New med.

Glucose
Caloric, parenteral solution
New med.

Heparin Flush
New med.

Hydralazine
Antihypertensive, direct
acting peripheral
vasodilator
Phthalazine

Insulin Glargine
(Lantus)
Antidiabetic, pancreatic

and in the loop of Henle.

To treat pts hypertension
and fluid in lungs.

12.5
g=25mL
injection IV
push as
directed prn
FSBG less
than 70
mg/dL
300 units =
3 mL inj.
flush

10mg=0.5m
L IV push
Q4h prn
SBP>140

25 units
subcut
Qbedtime

hyperuricemia, hyponatremia, ,
hyperglycemia, nausea, polyuria,
renal failure, thrombocytopenia,
agranulocytosis, leucopenia,
neutropenia, anemia, StevensJohnsons syndrome
Needed for adequate
Loss of consciousness, CHF,
utilization of amino
pulmonary edema, intracranial
acids; decreases protein,
hemorrhage, hyperglycemia
nitrogen loss, prevents
ketosis; given to prevent
or correct hypoglycemia
Lansoprazole and
hydrocortisone cause
hypoglycemia as a side
effect
Prevents conversion of
fibrinogen to fibrin and
prothrombin to thrombin by
enhancing inhibitory effects
of antithrombin III. To
prevent blood from clotting.
Flushed through lines to
prevent clots from forming
on the end of lines and to
keep blood thin since the
patient is on bedrest and
moves very little. For PICC
line.
Vasodilates arteriolar
smooth muscle by direct
relaxation; reduction in BP
with reflex increases in HR,
stroke volume, and CO

diet; orthostatic hypotension;

photosensitivity

Assess electrolytes and blood

glucose prior to giving, assess inj
site for extravasation
IV Push: may be given undiluted
via prepared sol., give 10% sol
5mL/15 sec. 50% sol 10mL/min.
control rate; rapid infusion may
cause fluid shifts, do not use
same inf. set as used for blood

Fever, hematauria, hemorrhage,

thrombocytopenia, anemia, rash,
anaphylaxis

Watch for bleeding, bruising,

decrease in Hct, B/P. Teach to
use soft bristle tooth brush,
product may be held during
menstruation. To keep clots from
forming on tips of catheters. Flush
when not in use.

Headache tremors, dizziness,

anxiety, palpitations, reflex
tachycardia, angina, shock N&V,
anorexia, diarrhea, leukopenia,
agranulocytosis,
thrombocytopenia, lupus like
symptoms

Assess B/P, Pulse, HR, assess

electrolytes, daily weight, I&O,
dyspnea, jugular distension, tech
to take with food, rise slowly
orthostatic hypotension

Anaphylaxis, hypoglycemia

Assess blood glucose, for signs of

hypoglycemia. Teach that blurred
vision may occur, to keep insulin

Decreases blood glucose

by transport of glucose into
cells and the onversion of

11

hormone; modified
structures of endogenous
human insulin
Long acting
new med.

Insulin Lispro
(Humalog)
Antidiabetic, pancreatic
hormone; modified
structures of endogenous
human insulin

Inj. Subcut
TID AC and
Qbedtime

New med.

Labetalol
Antihypertensive,
antianginal; -1/- blocker
New med.

LevETIRAcetam
(Keppra)
Anticonvulsant
New med.

Lisinopril
Antihypertensive ACE
inhibitor
Enalaprilat lysine analog
New med.

10mg 2 mL
IV push
Q2h prn
SBP > 150

500mg=5m
L IVPB
Q12h infuse
over 30
min.
20mg=1 tab
oral daily,
hold
SBP<100

glucose to glycogen,
indirectly increases blood
pyruvate, and lactate,
decreases phosphate and
potassium, insulin may be
human. PT is diabetic.
Decreases blood glucose
by transport of glucose into
cells and the onversion of
glucose to glycogen,
indirectly increases blood
pyruvate, and lactate,
decreases phosphate and
potassium, insulin may be
human. PT is diabetic.

Produces decreases in B/P

without reflex tachycardia
or significant reduction in
HR through mixture of blocking, -blocking
effects; elevated plasma
renins are reduced. Given
for increased BP.
Unknown; may inhibit
nerve impulses by limiting
influx of sodium ions
across cell membrane in
motor cortex. Pt has risk of
seizures after CVA
Selectively suppresses
RAAS; inhigints ACE,
thereby preventing
conversion of angiotensin I
to angiotensin II. To treat
pts hypertension.

Anaphylaxis, hypoglycemia

CHF, ventricular dysrhythmias,

agranulocytosis, thrombocytopenia,
purpura, exfoliative dermatitis,
bronchospasm

available at all times, to frequently

check blood glucose, to recognize
signs of both hypo and
hyperglycemia, that a diet should be
followed to keep blood sugar in
check
FSBG <140= 0 units
150-199= 2 unit
200-249= 4 units
250-299 = 6 units
300-349 = 8 units
350 and above= 12 units
Assess blood glucose, for signs of
hypoglycemia. Teach that blurred
vision may occur, to keep insulin
available at all times, to frequently
check blood glucose, to recognize
signs of both hypo and
hyperglycemia, that a diet should be
followed to keep blood sugar in
check
Hold for HR <65
Assess I&O for CHF, B/P for
hypertension, teach not to stop
abruptly should be tapered off, teach
to report bradycardia, to take med at
bedtime to prevent orthostaic
hypotension.
Give undiluted 5mg/mL over 2 min.

Suicidal ideation

Watch for seizures, Assess

mental status, behavioral
changes, teach patient to avoid
driving, not to discontinue quickly
withdrawal seizure may occur

Vertigo, stroke, fatigue, hepatic

failure hepatic necrosis, proteinuria,
Renal insufficiency, angioedema,
anaphylaxis, toxic epidermal
necrolysis

Assess platelets, WBC, renal and

hepatic studies. Teach not to
discontinue abruptly, rise slowly
for orthostatic hypotension, avoid
increasing potassium in diet,

12

report dry cough

Lorazepam
(Ativan)
Sedative, hypnotic,
antianxiety
Benzodiazepine, short
acting
New med.

Magnesium Oxide
Electrolyte, anticonvulsant;
saline laxative, antacid
New med.

Magnesium Sulfate
Electrolyte; anticonvulsant;
saline laxative; antacid
New med.

Metoprolol
Antihypertensive,
antianginal
BB
New med.

Nystatin Topical
Antifungal

0.5mg=0.25
mL injection
IV Q2-6h
PRN

Potentiates the actions of

GABA, especially in the
limbic system and the
reticular formation.
As needed for anxiety.

Dizziness, drowsiness,
orthostatic hypotension, EKG
changes, tachycardia, apnea,
cardiac arrest, blurred vision

Asses for physical dependency,

assist with ambulation. Teach that
drowsiness may occur, to change
positions slowly.
IV push: prepare immediately before
use; dilute in equal volume sterile
water, 5%dextrose, or 0.9%NaCl for
inj; give through Y tube or 3 way stop
cock; give at 2mg/min, do not give
rapidly

400mg=1
tab oral
Q12Hx2;
800 mg =2
tabs oral
Q12Hx2;

Increases osmotic
pressure, draws fluid into
colon, neutralizes HCl.
Treatment for seizures and
low magnesium.

Flaccid paralysis, circulatory

collapse, nausea and vomiting,
cramps

Assess eclampsia assess for

toxicity (thirst, confusion,
decrease in reflexes)

1g=100 mL
IV soln IV
PB infuse
over 1 hour

Increases osmotic
pressure, draws fluid into
colon, neutralizes HCl.
Electrolyte to be given
when magnesium levels
are low. Treatment for
seizures and low
magnesium.

Flaccid paralysis, circulatory

collapse, nausea and vomiting,
cramps

400mg for 1.4-1.8 mg/dL

800mg for 1.3mg/dL or less
1g=100mL for 1.4-1.8 recheck
after 4 Hours
Assess eclampsia assess for
toxicity (thirst, confusion,
decrease in reflexes)

Lowers B/P by Bblocking effects; reduces

elevated rennin plasma
levels, blocks B2
adrenergic receptors in
bronchial, VSM only at
high doses, negative
chronotropic effect. To
treat pts hypertension.
Interferes with fungal
DNA replication; binds

Insomnia, dizziness,
hypotension, bradycardia, cardia
arrest, AV block,
pulmonary/peripheral edema,
chest pain, agranulocytosis,
eosinophilia, thrombocytopenia,
purpura, bronchospasm

400mg for 1.4-1.8 mg/dL

800mg for 1.3mg/dL or less
1g=100mL for 1.4-1.8 recheck
after 4 Hours
Assess EKG, B/P, HR, notify
prescriber is < 50. Baseline renal
and hepatic studies. Teach to
take immediately after meals or at
night time, do not discontinue
abruptly, report dizziness, SOB,
monitor blood glucose closely

25mg= 1
tab oral BID

1
application

N&V, diarrhea, cramps

13

Assess allergic reaction, long

term treatment may be needed to

Amphoretic, polyene
New med.

powder BID
peri-anal
area

sterols in fungal cell

membrane, which
increases permeability,
leaking of cell nutrients.
To trat pts rash in perianal area.

Potassium Chloride

20mEq=15
mL
liquid/tab
oral,
40mEq=30
mL
liquid/tab
oral;
10mEq=10
0mL IV
soln,IV PB;

Needed for the adequate

transmission of nerve
impulses and cardiac
contraction, renal function,
intracellular ion
maintenance
To be given to pt when K
levels are low.

Cardiac depression, dysrhythmias,

arrest, peaking T waves, lowered R,
depressed RST, prolonged P-R,
widened QRS complex, N&V,
cramps

20mg= 1
tab oral
Qbedtime

Inhibits HMG-CoA
reductase enzyme, which
reduces cholesterol
synthesis. To treat
hyperlipidemia.

Liver dysfunction, pancreatitis,

myositis, rhabdomyolysis

20mL
injection
flush as
directed,
PRN for
central line
flush after
lab
draw/blood
transfusion
after
discontinuati
on of TPN,
and every 12
hr if unused;

To clear lines of all

medications and to keep
lines open, to prevent
clots from forming at the
tip of any IV catheter

Heart failure,

New med.

Simvastatin
(Zocor)
Antilipemic; HMG-CoA
reductase inhibitor
New med.

Sodium Chloride
NS Flush
New med.

clear infection, complete entire

course of medication

14

Assess for hyperkalemia, assess

K levels before given, monitor
I&O for decreased urinary output.
Monitor IV site when giving
potassium via IV for irritation
3.8-3.9mEq/L=20mEq x1
3.5-3.7mEq/L=40mEqx1
3-3.4mEq/L= 40mEq+20mEq
within 4H
2.9 or less 40mEq+40mEq within
4 H &notify physician
Monitor hepatic studies baseline
and periodically, BUN, I&O,
creatinine. Monitor for
rhabdomyolysis. Teach low
cholesterol diet
assess heart sounds, HR, BP,
Monitor for signs of clotting, flush
before and after something is
pushed through and Q 12 h if
unused

10mL pre
and post IV
med. Admin
and/or saline
lock per
protocol

15

Concept Mapping
Step 2. List clinical manifestations under each nursing diagnosis and other relevant data to support each diagnosis, including lab
data, medications, interventions, and assessment findings. All medical & nursing interventions should be found in one or more of the
boxes.
ND #1 decreased intracranial adaptive
capacity r/t brain injury, intracranial
hypertension

ND # 3: risk for aspiration

ND #4 neurological deficit r/t anoxic brain injury
Data to support: hypertensive intracranial
hemorrhage, L sided weakness, forgetful, not
oriented to own ability

Data to support: hypertensive intracranial

hemorrhage, lasix prescribed,

LA8/2011

16

Data to support: hypertensive

intracranial hemorrhage, pureed
diet, nectar thick foods and
liquids only, must take
spoonful at a time only, must sit
straight up

Concept Mapping
Evaluate Effects of Nursing Actions- Patient Outcomes, Documentation (Done During Clinical)
ND #2 risk for ineffective
cerebral tissue perfusion

Patient Response
1. ND/Nursing
Care:
#1
decreased
intracranial
adaptive
capacity
r/t brain injury, intracranial hypertension
Data to support:
Nursing
Actions(NIC)
hypertensive
intracranial
hemorrhage,
L sided signs
Assess
neurological
had left sided weakness, could not squeeze, push, or even move
Chief Medical Diagnosis:Pt
Hypertensive
weakness, forgetfulness
7. Discharge
w/
L side. Pt eyes reactive and round
but L eye sluggish, pt forgetful.
intracranial bleed
Pt
should
have seizures
under
Monitor I&O
Pt incontinent
5 times, pt took in 800mL saline
flush,
pt took in about
Priority Assessments: ABCs,
neuro
control with meds. B/P and HR
1,500mL
in
food/drink
Assessment, monitor B/P, HR, monitor RBC
8. Pt Education
should be under control with
Teaching
importance
controlling
Pt verbally
how and why
to control
check IVrepeated
site
Teach
pt/ pt family
to monitor of
I&O
in relation hypertension Hgb, Hct, PTT, trace the lines,
meds.
PT shouldhypertension
have no sign
importance
of controlling
Pt verbally repeated how and why to control
diabetes
toTeach
decreased
intracranial adaptive
capacity- diabetes
of infection.
Pts vital signs
family
not importance
present during teaching
should
be stable.
Pt oriented
Teach
of not using blood thinners
Pt verbally repeated why not to use
blood
thinners,
hadtono further Qs
Teach pt importance to small slow bites with
eating to reduce risk for aspiration needs
2. ND/Nursing Care: #2 risk for ineffective cerebral
reinforcement
Nursing
Actions(NIC)
Teach
pt importance
of low fat diet to reduce
Assess
neurological
atherosclerosis- pt verbalizedsigns
understanding
Teach family to assess and report any
neurological
changes.family not present
Monitor vital
signs
during teaching
Teach family/pt passive ROM and encourage
Teach
importance
ofmobility.-Pt
not using blood thinners
use
of weak
side to increase
Teach importance
verbalized
understanding of controlling hypertension
Teach
pt importance
of controlling
Teach
importance
of controlling diabetes
hypertension and diabetes- pt verbalized
understanding

own ability. Improvement of

left side strength and ROM. Pt
tissue perfusion
ND # 5impaired mobility r/t
should be compliant with
neurological changes
diabetes and hypertension
Pt had left sided weakness, couldmeds.
not Placement
squeeze,
or even move
in push,
long-term
Data to support: hypertensive
facility.but L eye sluggish, pt forgetful.
w/ L side.L-Pt eyes reactive and round
intracranial hemorrhage,
0800
VS
T
37.0
oral,
BP
144/84,
HR 86, SpO2 97% RA, R 20. 1200
sided weakness

VS T 36.1 oral, BP 140/83, HR 78, SpO2 96% RA, R 20

Pt verbally repeated why not to use blood thinners, had no further Qs
Pt verbally repeated how and why to control hypertension
Pt verbally repeated how and why to control diabetes

3. ND/Nursing Care: # 3: risk for aspiration

Nursing Actions(NIC)
Pt sitting upright to eat
Only allow nectar-thick liquids/foods

Pt tolerated upright position well

Pt requested water and soda several times, did not like the nectar
thick diet, wanted reevaluated
Pt not oriented to own ability, wanted to feed herself, would take too
much at a time, pt did not like being fed
0800 SpO2 97% on room air and 1200 SpO2 96% on room air
Pt would cough when asked, like to have bedpan under her when
coughing

Feed pt slow, small bites

Monitor SpO2
Encourage coughing
4. ND/Nursing Care: #4 neurological deficit r/t anoxic brain injury
Nursing Actions(NIC)
LA8/2011

17

Assess neurological signs

Monitor vital signs
Turn pt Q2h
Ensure pt can reach anything she needs with Rt hand
Passive ROM

5. ND/Nursing Care: # 5 impaired mobility r/t neurological changes

Nursing Actions(NIC)
Assess neurological signs
Remind pt of bedrest only
Ensure pt can reach everything w/ Rt hand
Passive ROM
Encourage L side use

LA8/2011

18

Pt had left sided weakness, could not squeeze, push, or even move
w/ L side. Pt eyes reactive and round but L eye sluggish, pt forgetful.
0800 VS T 37.0 oral, BP 144/84, HR 86, SpO2 97% RA, R 20. 1200
VS T 36.1 oral, BP 140/83, HR 78, SpO2 96% RA, R 20
Pt tolerated turning. Could help turn to rt side, could not help turn to
left side
Pt could only move with Rt side, call light and remote left within reach
of Rt hand, pt appreciated
Took two of us at times, pt tolerated passive ROM

Pt had left sided weakness, could not squeeze, push, or even move
w/ L side. Pt eyes reactive and round but L eye sluggish, pt forgetful.
Pt was not oriented to own ability, she wanted to get and do
everything for herself, pt a little resistant to being fed
Pt could only move with Rt side, call light and remote left within reach
of Rt hand, pt appreciated
Took two of us at times, pt tolerated passive ROM
Pt would rather use Rt side of body, pt would try to move left side
when asked, but could not move it at all

SOAP Note
S- A fifty-two year old woman admitted after reporting to ED on 10/11 with L sided facial droop.
Pt had had headaches for a couple weeks before waking up with the facial droop. CT scan
confirmed an intracranial hemorrhage due to uncontrolled hypertension. Pt has a history of
hypertension, diabetes, sleep apnea, and COPD. Pt was intubated after respiratory distress and
extubated on 10/22. Pt is alert and oriented, but can be forgetful and is not oriented to own
ability. Pt reported no home meds. Pt is being treated with lasix and other hypertension
medications. Pt will ask for bed pan , but is sometimes incontinent. Pt is on bed rest and pureed,
nectar thick diet for aspiration risk. 15 yr old daughter comes to visit every afternoon.
O- Pt is calm, but has moments of not wanting to cooperate. 0800 VS T 37.0 oral, BP 144/84,
HR 86, SpO2 97% RA, R 20. 1200 VS T 36.1 oral, BP 140/83, HR 78, SpO2 96% RA, R 20. Pt
reported headache intermittently and was treated with Norco.
Neuro- alert and oriented x3 can be forgetful and not oriented to own ability. Pt is drowsy and
hard to wake. Pt L eye is sluggish to react. Pt has L sided facial droop. Pt has L sided weakness,
cannot move L extremities at all. Pt cannot wiggle toes or fingers on L side. Pt is risk for
aspiration and on nectar thick pureed diet.
CV- Pt has normal rate and rhythm with S1 and S2 auscultated. No murmurs, clicks, or gallops.
Capillary refill brisk in all extremities. No edema present. Peripheral pulses 3+. 3-lumen PICC in
rt upper arm. Saline lock.
Resp-Lungs sounds slight crackles and diminished at bases. Patient tolerated cough and deep
breathing. Respirations were slightly labored. Pt fatigued easily
GI- pureed, nectar thick diet. Abdomen soft and rounded, bowel sounds active x 4. No pain or
masses on palpation. Last BM 10/23.
GU- Pt incontinent at times. Bright yellow urine.
Skin: Skin intact. Rash on peri-anal area being treated with Nystatin powder. Pt reports skin
itching under tegaderm, possible skin blister or rash on edge of tegaderm. Skin throughout is
normal for patient. Pillow case placed between skin folds to keep area clean and dry. No other
signs of skin breakdown.
A- Intracranial hemorrhage due to hypertension
P- Bed rest. Medicate pt to control hypertension, diabetes, and hyperlipidemia. Give lasix to help
with hypertension and to help clear lungs. Passive ROM and encourage use for L side. Monitor
for seizures and neurological decline. Monitor I&O. Pt on pureed nectar thick diet to decrease
aspiration risk. Pt to sit upright and take slow small bites.

LA8/2011

19