California State University, Stanislaus

School of Nursing
N4810 Adult Health Nursing II Clinical
3 units
DIRECTIONS FOR COMPLETING THE CLINICAL PLAN OF CARE
The Clinical Preparation Form is considered homework in which the student prepares to give nursing care
by first reviewing pertinent aspects of patient care specific to the patient selected during the clinical
experience. The worksheet must be completed prior to the beginning of the clinical learning experience.
There are a number of sections to this worksheet and each section is to be completed. The following are
the directions for completing the worksheet. If you have any questions about completing the worksheet
or regarding instructor comments on you work, please contact your clinical instructor as soon as possible.
Submit electronically, unless specified otherwise by your clinical instructor.
Student/Date: Include your full name and the date of the clinical experience
Patient Initials/Medical Record Number/Ethnic or Cultural Background: Do not use the name of the
patient, use only the patient's initials and medical record number. Don't forget to include information
about your patient's cultural background.
Admission Date: Identify the date of admission to the hospital.
Admitting Diagnosis: Identify the admitting diagnoses of the patient.
Other Diagnosis/Surgical Procedures: Look on the H&P, the admitting note, the nursing history and the
operative note. If applicable identify all medical diagnosis and surgical procedures done currently or in
the past.
Allergies: Note specific allergies. If none, write "none" or NKDA"
Diet: Identify the specific diet for patient
Intake and Output (I & O): Indicate if the patient is on I & O includes all pts. receiving IV therapy
IV: Indicate the type and location of IV, type of solution and the rate per hour.
Invasive Tubes: Indicate any invasive tubes that are present.
Pertinent Laboratory & Diagnostic Information: Identify the date of the lab work, low or high values
accompanied by arrows up or down to demonstrate the trend.
Medications: Identify the name of the drug, both generic and trade, mechanism of action, side effects,
rationale, and nursing implication and patient teaching. This should be done for every medication the
patient is receiving. Use your drug book.
Patient Care Plan: Review the pt. care plan for accuracy and thoroughness. Make any changes you feel
are appropriate. For example, add a problem which you feel needs to be included. Describe the expected
outcome and the appropriate nursing interventions.

N4810 Clinical Paperwork Rev 11/6/13

CSU, STANISLAUS B.S.N.

CLINICAL PLAN OF CARE
Patient Data
Student: Kaylee Blankenship Date of Care: 3/12/15-3/13/15 Room Number: 4721-A Code Status: FULL
Pt. Initials

D.R. Gender: Female Age: 88 Height: 5 Weight: 50.1 kg (110 lbs) BMI: 21

Spirituality: Protestant Ethnicity: Caucasian

Admitting Diagnosis: Hypoglycemia

Vital Signs: Temp 97.7 F (36.5 C) HR 110 RR 18 B/P 159/65 O2 Sat 95 Pain Scale & Scale Type 0 out of 10
History related to this admission: type II DM w/o mention of complication
Past Medical History: HTN essential. Abnormal heart sounds, motion sickness, type II DM w/o mention of complication, arthropathy unspecified,
cervcalgia, GERD, hyperlipidemia
Admit Date: 3/9/15 POD: :

Surgical History & Date: shoulder surgery-left side (2008), left knee replacement (2000), appendectomy (1945), tonsil removal (less than 12 yr),
extracap cataract removal w/IOL (9/2009)
MD(s): Ahire
Diet: soft diet w/ 1:1 feeder Activity: ambulate with assist
Feeding Tube & Rate :

Advance Directive: Yes ________ No X

Isolation:
VS Freq: q4hr per unit protocol
Vascular Access:

Foley: indwelling single lumen cath (3/9/15)

Drains/ Tubes:
Glucose Monitoring: yes (AC and HS) DVT Prophylaxis: SCDs
PCA/Epidural:
Telemetry & Rhythm: 5-lead (sinus tachycardiamost of the time)
IV Site: right forearm IV Solution & Rate: NaCl 0.9% 75 ml/hr Safety Considerations: fall precautions, aspiration, confusion, restraints
Restraints: side rails up, vest/jacket, soft bilateral wrist restraints on 3/11/15. Had no restraints and just a sitter 3/12/15-3/13/15
Dressing Changes & Frequency:
Labs for day of clinical: BMP w/ GFR routine daily, Mg routine daily am, Mg routine after replacement prn, K routine after replacement prn, CBC
with auto differential routine daily
Scheduled Procedures: Echocardiogram 3/13/15
Procedures done this admission:
Oxygen: room air
Respiratory Treatment:
Vent Settings:
Allergies: NKDA
Advanced Hemodynamic Monitoring & Values:
IV Drips Medications Dosage & Rate:

_________________________
________________________
________________________
__________________________
________________________

N4810 Clinical Paperwork Rev 11/6/13

Notes on Pathophysiology
Medication
Generic & Trade Name Dose,
Route, Frequency
Acetaminophen (Tylenol)
650 mg PO q4hr prn

Mechanism of Action
Classification
Analgesic, antipryretic;
synthetic nonopioid paminophenol derivative

Patient-Specific Rationale
For mild pain 1-3 or temp above 38
degrees C as indicated on MAR. Pt has
arthropathy which can sometimes casue
mild aches and pains.

Action: Pain reduction may result

from inhibition of prostaglandin
synthesis in CNS, with subsequent
blockage of pain impulses. Fever
reduction may result from
vasodilation and increased
peripheral blood flow in
hypothalamus.

Ascorbic acid (vitamin C)

1,000 mg PO daily

Aspirin
81 mg tab PO chewable daily
with breakfast

Vitamin C-water soluble vitamin

Dietary supplement for deficiency.

Action: wound healing collagen

synthesis, antioxidant,
carbohydrate metabolism

Analgesic; NSAID
- Action: A potent inhibitor of both
prostaglandin synthesis and
platelet aggregation than its other
salicylic derivatives due to the
acetyl group on the aspirin
molecule, which inactivates
cyclooxygenase via acetylation.

Decreases platelet aggregation (blood

thinner), which is what the patient needs
in order to help prevent blood clots. Pt
also has history of HTN.

Nursing Considerations
(Assessment implications, side effects, reasons to hold
med, administration rate, etc)
Side effects: Pruritis, constipation, nausea, vomiting,
insomnia, agitation, atelectasis, Stevens-Johnson
syndrome, toxic epidermal necrolysis, pneumonitis,
thrombocytopenia, hemolytic anemia, neutropenia,
leukopenia, pancytopenia, hepatotoxicity, hypoglycemic
coma
Considerations:
-Know that drug may cause hepatic toxicity at high doses.
-S/s of hepatic toxicity include dark urine, clay-colored
stools; yellowing of skin; abdominal pain; fever or
diarrhea.
-Monitor for hepatic and renal lab values.
-Watch for s/s of chronic poisoning such as rapid, weak
pulse; dyspnea; cold, clammy extremities.
-Monitor pt for s/s of allergic reaction such as rash or
urticaria.
-Monitor for effectiveness through fever reduction or pain
reduction.
-Advise pt that it is unsafe to take more than 4 grams of
acetaminophen in a 24-hr period.
-Instruct pt not to use this med with alcohol.
-Perform teaching on the presence of acetaminophen in
other medications. Instruct pt to take medication with a
full glass of water.
Side effects: headache, fatigue, diarrhea, anorexia,
heartburn, cramps, polyuria, urine acidification,
oxalate/urate renal stones, dysuria, hemolytic anemia
Considerations:
-Assess I&O ratio, urine pH, ascorbic acid levels,
nutritional status, and for thrombophlebitis.
-Teach pt necessary foods to include in diet (i.e. citrus
fruits) and do not exceed prescribed dose.
Side effects: Gastrointestinal ulcer, bleeding, age related
macular degeneration, tinnitus, bronchospasm,
angioedema, Reyes syndrome
Considerations:
-Take medication with a full glass of water (8 ounces or
more) or food.
-Monitor CBC, chemistry profile, BP, fecal occult blood
test, LFTs.
-Instruct pt to report s/s of bleeding or GI distress.
N4810 Clinical Paperwork Rev 11/6/13

- Pt may take with food or milk.

-Instruct pt to avoid alcohol during therapy.

Bisacodyl (Dulcolax)
10 mg suppository daily prn

Calcium carbonate/vitamin D
(caltrate 600+D)
600 mg/400 Unit 2tab PO daily

Laxative; Stimulant
Action: Acts directly in the
intestines by increasing motor
activity; thought to irritate colonic
intramural plexus

Anatacid; calcium supplement

Action: Reduces total acid load in
GI tract, elevates gastric pH to
reduce pepsin activity, strengthens
gastric mucosal barrier, and
increases esophageal sphincter
tone.

Ordered prn to prevent constipation due

to pts limited mobility (intermittently on
restraints due to decreased LOC)

This is used to help with the pts GERD

to reduce acidity level of GI secretions.
Vitamin-D is also for a supplement. This
might be because many patients are being
found to be vitamin D deficient so it is
precautionary in a way.

Side effects: Abdominal colic, abdominal discomfort,

diarrhea, proctitis with suppository use, atony of colon.
Considerations:
-After administration, retain medication for about fifteen
to twenty minutes.
-Monitor for signs of effectiveness such as decreased
abdominal discomfort and pain and a BM within 15 to 60
minutes.
-Reassess pt if recta, bleeding or no BM occurs after 12
hours.
- Perform ot teaching about how drug can cause diarrhea
or abdominal pain, discomfort, and cramping.
-Pts should not take med for more than 7 days unless
approved by a health care professional.
-PR administration: explain procedure to pt, ensure pt
privacy, position pt into sims position , apply clean
gloves, and insert medication gently through anus and
past the internal sphincter and against the rectal wall.
While inserting the medication, tell pt to take slow deep
breaths through the mouth and to relax the anal sphincter.
Side effects: Headache, irritability, weakness, nausea,
constipation, flatulence, rebound hyperacidity
Considerations:
-Know that drug may cause an increase in calcium levels
and may cause a decrease in phosphate levels.
-Record the amount and consistency of stools, and
manage constipation with laxatives or stool softeners.
Monitor calcium levels, especially in pts with mild renal
impairment.
-Calcium should be 8.5-10.5, urine calcium should be
150 mg/day
-Watch for evidence of hypercalcemia such as nausea,
vomiting, headache, confusion and anorexia.
-Perform teaching with patient against taking in an
indiscriminant routine and against switching antacids
without the prescribers advice. Urge pt to notify
prescriber about s/s of GI bleeding such as tarry stools, or
coffee-ground vomitus.

N4810 Clinical Paperwork Rev 11/6/13

Clopidogrel (Plavix)
75 mg PO daily

Dextrose (GLUTOSE)
15 g oral gel prn

30 g oral gel prn

Dextrose 50%
12.5 g IV inj prn

Platelet aggregation inhibitor

Action: Inhibits ADP-induced
platelet aggregation. This is for her
peripheral arterial disease, which
works as an anticoagulant.

Action: raises blood glucose

levels. For patients experiencing
acute hypoglycemia. Provides a
source of water and carbohydrates.
The simple carbohydrate may
minimize liver glycogen depletion
and provide protein-sparing action.

Action: Prevents protein and

nitrogen loss; promotes glycogen
deposition and ketone
accumulation. acute hypoglycemia

Helps reduce the pts future risk of stroke

since she has HTN and a history of
abnormal heart sounds.

For blood glucose of 45-69 mg/dL or

greater if patient is symptomatic, if
patient conscious and able to chew.
This is ordered in case the patient
becomes hypoglycemic again like she
was on admission.
For blood glucose less than 45 mg/dL, if
patient conscious and unable to chew
-Same as above
For blood glucose of 45-69 mg/dL or
greater if patient is symptomatic. If
patient has an IV and unable to swallow.
This is ordered in case the patient
becomes hypoglycemic again like she
was on admission.

Side effects: Headache edema, hypertension, chest pain,

constipation, GI bleeding, pancreatitis, hepatic failure,
hypercholestremia, UTI, fatigue, bronchospasm, dyspnea,
bronchitis
Considerations:
-Assess for pt for thrombotic/thrombocytic purpura: fever
thrombocytopenia, neurolytic anemia
-Symptoms of stroke or MI during treatment
-Hepatic studies: AST/ALT bilirubin, creat
-Blood studies: CBC, differential, HCt, Hgb, PT,
cholesterol.
-Teach pt that blood work will be necessary during
treatment. Teach pt to report any unusual
bleeding/bruising and to take the medication with food to
minimize GI upset. Report diarrhea, skin rash, subQ
bleeding, chills, fever, or sore throat. Inform pt to tell all
health care providers that he/she is using this medication.
Side effects: Hyperglycemia, hyperosmolarity, cerebral
hemorrhage, cerebral ischemia, pulmonary edema
Considerations:
-Assess: I&O (make sure patient is receiving adequate
hydration and electrolyte balance)
-Check electrolytes and blood and urine glucose
-Shake well before using

Side effects: Venous thrombosis, heart failure,

hyperosmolar coma, pulmonary edema, hyperglycemia,
hypertension, flushing
Considerations:
-Administer bolus over 5-10 mins
-Infuse concentrations above 10% through central vein.
Do not infuse rapidly, doing so may cause hyperglycemia
and fluid shifts. Never stop infusion abruptly. Monitor
infusion site frequently to prevent irritation, tissue
sloughing, necrosis, and phlebitis.
-Assess: electrolytes and calorie count
-Check blood glucose at regular intervals.
-Monitor I&O. Monitor weight regularly and assess
patient for confusion. Teach pt how to recognize s/s of
hypo and hyperglycemia. And blood glucose monitoring
procedures.
N4810 Clinical Paperwork Rev 11/6/13

25 g IV inj prn

Glucagon (Glucagen Hypokit)

1 mg IM inj prn

Same as above

Glucose Chew tab

16 g Chew tab PO prn
32 g Chew tab PO prn

Heparin
5,000 units subQ q12hr

For blood glucose less than 45 mg/dL. If

patient has an IV and unable to swallow.

Action: Induces liver glycogen

breakdown and glucose release,
relaxes GI smooth muscle. Raises
blood glucose levels. For patients
experiencing acute hypoglycemia.

Action: raises blood glucose

levels. For patients experiencing
acute hypoglycemia.

Anticoagulant, antithrombotic
-Action: Prevents conversion of
fibrinogen to fibrin and
prothrombin to thrombin by
enhancing inhibitory effects of
antithrombin III

Hydralazine (apresoline)

Antihypertensive, direct-acting
peripheral vasodilator

10 mg IV inj q6hr prn

Action: Vasodilates arteriolar
smooth muscle by direct
relaxation; reduction in blood
pressure with reflex increases heart

-Same as above
For blood glucose of 45-69 mg/dL or
greater if patient is symptomatic. If
unable to obtain IV access and unable to
swallow.

For blood glucose less than 45 mg/dl. If

unable to obtain IV access and unable to
swallow.

-Administer IV bolus over 5-10 mins

Same as above

Side effects: Hypotension, hyperglycemia

Considerations:
-Monitor: blood glucose levels and level of
consciousness.
-Teach: Be familiar with technique for administration in
case of emergency, seek medical assistance if no response
is seen within 15 mins of glucagon injection, once
response has occurred patient should be given oral
carbohydrate. This will restore liver glycogen and avoid
recurrence of hypoglycemia,

For blood glucose of 45-69 mg/dL or

greater if patient is symptomatic.
If patient is conscious and able to
swallow.
For blood glucose less than 45 mg/dL.
If patient is conscious and able to
swallow.

-Do not swallow whole.

-May administer 4 oz of juice INSTEAD of glucose tabs.

For prevention of DVT due to patients

limited mobility due to restraints ordered
because of the pts altered LOC.

Side effects: Fever, chills, headache, hematuria,

hemorrhage, thrombocytopenia, anemia, rash, delayed
transient alopecia, hematoma, cutaneous necrosis,
hyperkalemia, hypoaldosteronism, anaphylaxis

Ordered to lower pts BP because she has

HTN. Acts as a vasodilator thus reducing
pressure within the vessels, lowering BP.
This medication is more of an immediate
actor since it is IV rather than a slower
acting PO medication (which she also has
ordered).

-Do not swallow whole.

-May administer 8 oz of juice INSTEAD of glucose tabs.

Considerations:
-Assess: bleeding, hemorrhage, blood studies (Hct, occult
blood in stools) q3 months, PTT, platelet count,
hypersensitivity (rash, chills, itching).
-Teach: product may be held during active bleeding. Use
soft bristle toothbrush to avoid bleeding gums, carry
emergency ID, report to prescriber any signs of bleeding
or hypersensitivity
Side effects: Peripheral neuritis, depression, fever, chills,
palpitations, reflex tachycardia, shock, angina. Rebound
hypertension, orthostatic hypotension, constipation,
urinary retention, leukopenia, anemia, thrombocytopenia,
nasal congestion, muscle cramps, flushing, edema,
dyspnea.
N4810 Clinical Paperwork Rev 11/6/13

rate, stroke volume, cardiac output

Insulin lispro human

(Humalog KWIKPEN)
Inj Pen 1-6 units subQ tid 30
mins before meals

Magnesium Hydroxide (Milk

of Magnesia)
30 ml oral suspension PO daily
prn

Antidiabetic, pancreatic
hormone; modified structures of
endogenous human insulin

This is used to lower the patients glucose

level due to her Type 2 DM (use sliding
scale)

Action: Decreases blood glucose

by transport of glucose into cells
and the conversion of glucose to
glycogen, indirectly increases
blood pyruvate and lactate,
decreases phosphate and
potassium.

Mineral; Antacid
Action: Increases osmotic
gradient in small intestine, which
draws water into intestines and
causes distention. These effects
simulate peristalsis and bowel
evacuation.

This is ordered prn in order to prevent

constipation as a result of the patients
limited mobility form restraints.

Considerations:
-For IV administration: each 10 mg over 1 minute
-DBP> 95
-SBP>165
-Assess: cardiac status, electrolytes (K, Na, Cl, CO2,
CBC, glucose. Weight daily, edema, crackles, dyspnea,
orthopnea. IV site for extravasation. Mental status,
-Teach: to take with food, avoid OTC preps. Notify
prescriber if chest pain, severe fatigue, fever, muscle or
joint pain
Rise slowly
Side effects: Blurred vision, dry mouth, flushing,
lipodystrophy, lipohypertrophy, swelling, hypoglycemia,
rebound hyperglycemia, peripheral edema
Considerations:
-Sensitive regimen
-Dont hold if NPO
-Give the following correction insulin in addition to any
nutritional insulin.
-For blood glucose:
70-200 mg/dL: 0 units
201-250 mg/dL: 2 units
251-300 mg/dL: 3 units
301-350 mg/dL: 4 units
351-400 mg/dL: 5 units
Greater than 400 mg/dL, draw serum blood glucose,
administer 6 units and notify prescriber
-Assess: fasting blood glucose, A1c, urine ketones,
hypoglycemic reaction (sweating, weakness, dizziness,
confusion, headache, rapid weak pulse, fatigue,
tachycardia, slurred speech, staggering gait, acetone
breath, hunger
-Teach: keep insulin equipment available at all times
(carry a glucagon kit, candy or lump of sugar), does not
sure diabetes, carry emergency ID as diabetic, recognize
hypoglycemia reactions (headache, tremors, fatigue,
weakness) and hyperglycemia (frequent urination, thirst,
fatigue, hunger). Symptoms of ketoacidosis (polyuria, dry
mouth, increased BP, acetone breath, Kussmaul
Side effects: Confusion, decreased reflexes, dizziness,
syncope, paralysis, hypothermia, hypotension,
arrhythmias, circulatory collapse, nausea, vomiting,
cramps, flatulence, anorexia, hypermagnesemia,
hypocalcemia, muscle weakness, diaphoresis, allergic
reaction
Considerations:
N4810 Clinical Paperwork Rev 11/6/13

Magnesium Sulfate
2g in water in 50 ml IVPB
(premix) prn

3g in dextrose 5% 100 ml IVPB

prn

Electrolyte, anticonvulsant,
saline laxative, antacid
Action: Increases osmotic
pressure, draws fluid into the
colon, neutralizes HCl

For electrolyte replacement. The pts Mg

level has been intermittently low which
could possibly be due to malnutrition
caused decreased food intake because of
confusion and being placed on restraints.

-Shake well before using

-Follow dose with full glass of water.
-Assess for the cause of constipation. Perform pt
teaching about adverse reactions. Know that this
medication may delay absorption of other drugs. Instruct
pt that prolonged use of this medication can lead to
laxative dependence. Perform teaching on how a healthy
diet and regular exercise can reduce the need for
laxatives. Monitor electrolyte and liver function tests
while administering this medication. Monitor I&O.
Continue to monitor for medication effectiveness by
assessing the abdomen (looks, listen, feel) and asking the
pt regularly about BMs.
Side effects: muscle weakness, sweating. Confusion
flaccid paralysis, hypothermia, hypotension, heart block,
circulatory collapse, vasodilation, diarrhea, prolonged
bleeding time, electrolyte, fluid imbalances, respiratory
depression/paralysis
Considerations:
-Mg between 1.5-1.8 mg/dL
-Refrigerate
-Watch patient for s/s of magnesium toxicity: thirst,
confusion, decrease in reflexes, I&O ration, check for
decrease in urinary output
-Teach pt the reason for administration and expected
results.
-Mg between 1.2-1.4 mg/dL
-Refrigerate

Mg between 0.9-1.1 mg/dL

4g in sterile water 100 mL

Metoprolol tartrate
(Lopressor)
50 mg tab PO bid

Beta-adrenergic blocker;
cardiovascular agent
Action: Selective activity on beta1 adrenoreceptors located mainly
in cardiac muscles. At higher
doses, it may inhibit beta-2
adrenoreceptors of bronchial and
vascular smooth muscles. Possible
mechanisms of antihypertension
effects include: competitive
antagonism of catecholamines at

Given to this pt to lower her BP because

she has a history of HTN. However, this
medication ended up being d/c because
her heart rate would drop rapidly after
administration and then sky rocket again
in the 100s after the medication wore off.
The doctors suspected sick sinus
syndrome (SSS) as the cause.

Side effects: Bronchospasm, bradyarrhythmia, heart

block, heart failure, hypotension, constipation, diarrhea,
nausea, dizziness, headache, depression, dyspnea.
Considerations:
-Hold for systolic blood pressure less than 90 or heart rate
less than 60
Instruct pt to take with or immediately following meals.
Swallow tab whole with glass of water.
-Monitor BP regularly and especially near the end of the
dosing interval to confirm 24-hr hypertension control.
-Monitor BP, HR and ECG in early treatment to assess
N4810 Clinical Paperwork Rev 11/6/13

peripheral and cardiac adrenergic

receptors, a central effect leading
to reduced sympathetic outflow,
and suppression of rennin activity.

Potassium chloride
10 mEq in sterile water 100ml
IVPB premix daily prn

Electrolyte/mineral replacement;
potassium
-Action: Needed for the adequate
transmission of nerve impulses and
cardiac contraction, renal function,
intracellular ion maintenance

Potassium chloride CR
(KCOR-CON, KDUR)

Mineral and electrolyte

replacement; supplement

10-40 mEq PO daily prn

-Action: Maintain acid-base

balance, isotonicity, and
electrophysiologic balance of the
cell, activator in many enzymatic
reactions, transmission of nerve
impulses, contraction of cardiac,
skeletal and smooth muscle.

In case of hypokalemia The patients

levels were actually high on admission,
but then remained WNL the following
days. This must have been ordered as a
precaution on the doctors part due to pts
age and possible malnutrition resulting
from decreased/altered LOC.

Same as above (just in PO form)

for MI. Regularly monitor HR and rhythm during

therapy.
-Teach pt to avoid of activities requiring coordination
until drug effects are realized. Advise pt to report s/s of
cardiac failure such as pulmonary edema, dyspnea,
cyanosis, peripheral edema, hepatomegaly. Be aware that
durg may mask s/s of hypoglycemia. Advise pt to take ER
tabs after meals.
-DO NOT ABRUPTLY STOP TAKING MED. The
dosage should be gradually reduced over a period of 1 to
2 weeks.
Side effects: Confusion, bradycardia, cardiac depression,
dysrhthymias, and arrest, pain, diarrhea, ulceration of
small bowel, oliguria, cold extremities
Considerations:
->3.5 NO replacement
-Potassium 3.1-3.4-administer KCL 10 mEq in 100 mL
sterile water over 1 to 2 hours.
-Potassium 3.0 or below administer KCL 10 mEq in 100
mL sterile water over 1 hour in 4 divided doses. If patient
is NPO or not able to tolerate PO
-<2.9 KCl 10mEq in 100 ml steril water over 1-4 hrs plus
coadminister 40 mEq po dose
-Document each KCl replacement does seperatley on
eMAR
-Use peripheral or central line
-Notify physician if >80 mEq of KCl/ 24hr is
administered
-Administer dose if creatinine less than or equal to 2.0
-Assess hyperkalemia, potassium level, hydration status,
I& ratio, cardiac status
-Teach pt to add potassium rich food to their diet, avoid
OTC, report hyperkalemia/hypokalemia symptoms
(lethargy, confusion, decreased output), dissolve powder
or tablet completely,
Side effects: Arrhythmias, heart block, cardiac arrest,
hyperkalemia, respiratory paralysis
Considerations:
Potassium replacement scale:
3.5-4.0= 20 mEq KCl po once
3.0-3.4= 40 mEq KCl po once
less than or equal to 2.9= 40 mEq po once with 40 mEq
IV
-Administer dose if creatinine less than or equal to 2.0
-Dont crush/ chew and take with food
Document each KCl replacement does separately on
N4810 Clinical Paperwork Rev 11/6/13

eMAR
-Monitor vital signs and ECG. Do not administer drug if
apical pulse or BP is low. Particular caution must be used
in the administration of K-Dur to this pt because she has
a first degree heart block and potassium supplements can
cause heart block. Monitor renal function and check
BUN and creatinine labs often. Pay careful attention to
potassium lab values and monitor daily. DO NOT
ADMINISTER MED IF POTASSIUM LEVELS ARE
GREATER THAN NORMAL. Educate pt on ways to
consume potassium through their diet by eating leafy
greens, avocado, bananas, potatoes, and beans.
Pravastatin (pravachol)

Antilipemic; HMG-CoA
reductase enzyme

80 mg tab po daily
Action: Inhibits HMG-CoA
reductase enzyme which reduces
cholesterol synthesis

Risperidone (Risperdal)

Antipsychotic
Benzisoxazole derivative

0.25 mg tab po daily

Action: Unknown; May mediate
through both dopamine and
serotonin antagonism.

For patients history of hyperlipidemia. It

helps reduce the levels of LDL and
triglycerides in the blood, while
increasing the levels of HDLs.

Used to treat patients confusion and

altered LOC. It was working for the first
couple of days, however, the doctor d/c it
because it was causing pauses in the
patients cardiac rhythm.

Side effects: fatigue, chest pain, constipation, diarrhea,

abdominal pain, heartburn, hepatic dysfunction,
pancreatitis, hepatitis, renal failure, myalgia, rhinitis,
cough
Considerations:
-Assess fasting lipid profile (LDL, HDL, triglycerides),
hepatic studies (AST, ALT, LFTs may increase), renal
studies (BUN, I&O ratio, creatnine), rhabdomyolysis
(muscle tenderness and pain).
-Teach that blood work will be necessary during
treatment. Teach patient to report blurred vision, sever GI
symptoms, muscle pain, weakness, and fever. Pt should
follow low cholesterol diet and an exercise program
-Side effects: EPS, dystonia, tardive dyskinesia,
insomnia, drowsiness, seizures, neuroleptic malignant
syndrome, suicidal ideation, orthostatic hypotension,
tachycardia, heart failure, constipation, jaundice, weight
gain, hyperprolactinemia, neutropenia, upper respiratory
infection
Considerations:
-Assess for suicidal thoughts/behaviors. Make sure the
patient swallowed the medication
-Assess I&O, bilirubin, CBC, hepatic studies, urinalysis,
affect, orientation, LOC, reflexes, and sleep pattern.
-Monitor pts B/P for s/s of dizziness, faintness,
palpitations, tachycardia, EPS, and neuroleptic malignant
syndrome. Assess for constipation, urinary retention,
weight gain, hyperglycemia, and metabolic changes.
-Teach the pt that orthostatic hypotension may occur;
avoid hot tubs, abrupt withdrawal from medication, OTC
preparations, and hazardous activities. Teach the pt to
comply with medications and to notify the prescriber
immediately if suicidal thoughts/behaviors occur.
N4810 Clinical Paperwork Rev 11/6/13

LABORATORY DATA
LABS

Normal Range
(Fill in
Hospital
Norms)

RESULT 1
(3/9/15 @
0949)

WBC
RBC

4.0-11.0 K/uL
4.40-6.0 M/uL

5.7
4.07

7.0
3.61

7.3
3.76

6.5
3.36

Hemoglobin

13.5-18.0
g/dL

12.4

11.1

11.6

10.5

Hematocrit

40-52%

37.8

33.5

34.9

31.2

135

139

140

140

CBC

CHEMISTRY
Sodium

136-145
mmol/L

RESULT 2
(3/10/15
@0427)

RESULT 3
(3/11/15 @
0347)

RESULT 4
(3/13/15
@0415)

Reason for abnormal lab

values r/t diagnosis &
nursing implications
WNL
This patients levels have
been trending down since
admission. This may be
due to a dietary deficiency
or renal disease caused by
the pts type 2 DM or age.
However, since this
number has been trending
down since admission
possibly indicating
bleeding is taking place.
The pt should be
monitored for s/s of
hemorrhage including
abdominal pain/swelling,
light-headedness, large
area of deeply purple skin
(ecchymosis), increased
HR, decreased BP.
This patients levels have
been trending down since
admission. May indicate
bleeding. The pt should be
monitored for s/s of
hemorrhage including
abdominal pain/swelling,
light-headedness, large
area of deeply purple skin
(ecchymosis), increased
HR, decreased BP.
This patients levels have
been trending down since
admission. May indicate
bleeding. The pt should be
monitored for s/s of
hemorrhage including
abdominal pain/swelling,
light-headedness, large
area of deeply purple skin
(ecchymosis), increased
HR, decreased BP.

Pt was slightly low on

admission; however,
during her hospital stay
she had remained WNL.
Monitor for s/s of
worsening hyponatremia
such as N/V, headache,
confusion, loss of energy,
restlessness, muscle
weakness/spasms, or
N4810 Clinical Paperwork Rev 11/6/13

Potassium

5.4

4.0

3.5

4.4

Chloride
Glucose

3.5-5.1
mmol/L
98-107mmol/l
70-99mg/dl

101
228

103
187

106
190

107
165

Calcium
Magnesium

8.2-10.2
1.8-2.4mg/dl

9.5

9.6

8.8
1.1

8.7
1.8

LIVER PANEL
AST

0-37 U/L

49

39

cramps, seizures, coma,

and signs of heart failure.
Continue with IV fluids
and monitor pts I&O.
WNL
WNL
The initial lab value was
high, which is due to
measures that were taken
on admission to replace
her glucose level when
they found out that she
was hypoglycemic. The
pts glucose level
remained higher than
normal since she has type
2 DM. It was managed
with insulin lispro on a
sliding scale. Pts blood
sugar levels should
continue to be monitored
(AC/HS). Monitor for s/s
of hypoglycemia
including confusion,
abnormal behavior, vision
disturbances, shakiness,
anxiety and sweating.
Monitor for s/s of
hyperglycemia including
frequent urination,
increased thirst, blurred
vision and headache.
WNL
These levels were lower
than expected. This may
be due to malnutrition
since the patient has been
on restraints and not
eating as much as usual
or it could be due to renal
disease. Some
medications can become
toxic to the kidneys
causing damage.
Replacement should be
initiated according to
MAR scale. Monitor
patient for s/s of
hypomagnesmia including
abnormal eye movements,
convulsions, fatigue,
muscle cramps/spasms,
muscle weakness, and
numbness.

This could be high due to

an acute liver injury. The
pt was admitted for
hypoglycemia, possibly
N4810 Clinical Paperwork Rev 11/6/13

from taking too much

insulin which has the
potential to cause hepatic
injury.
WNL

ALT
KIDNEY PANEL
BUN

0-60 U/L

26

26

12-20 mg/dl

22

28

19

22

Creatnine

1.4-1.78
ml/sec

1.41

1.45

0.94

0.96

GFR

>=60

33

32

54

53

UA collection type
Urine glucose

Negative

>500

The patients levels were

slightly high which
indicates that she just isnt
getting good perfusion
possibly verging on ARF.
Pt. may also be
dehydrated after being in
restraints and little intake.
Her age also plays a
factor in proper renal
function. Monitor
patients I&O.
Pts level fluctuated
between WNL. This could
be decreased due to acute
renal failure from
hypoglycemia (overdose
of insulin). I could also be
slightly low since the
patient it older. As one
ages, creatnine levels
decrease. Monitor
patients I&O.
The patients levels are
lower than expected.
Watch for s/s of kidney
disease such as low
output, low appetite,
nausea and vomiting, and
persistent fatigue. Note
that age, gender, height,
race and weight can
influence the glumerular
filtration rate. Creatnine
should be monitored in
congruence with this
value in order to evaluate
kidney function.

This elevated level is due

to her type 2 DM., so the
pt is experiencing
glycosuria Since the pt
came in with
hypoglycemia they were
quickly trying to correct
this which is probably
why we see so much in
the urine. She is being
loaded up with glucose so
a lot is getting excreted
through the urine.
Monitor for s/s of
hypoglycemia including
N4810 Clinical Paperwork Rev 11/6/13

Urine Protein

Negative

confusion, abnormal
behavior, vision
disturbances, shakiness,
anxiety and sweating.
Monitor for s/s of
hyperglycemia including
frequent urination,
increased thirst, blurred
vision and headache.
Proteinuria is typically an
indicator of renal disease.
It could also be high due
to the patients diabetic
complications with
hypoglycemia.

30

DIAGNOSTIC DATA
TEST
ECG: 5 lead
X ray: chest (due to SOB)
MRI (for altered LOC)
CT: brain w/o contrast (for altered LOC)

CT: cervical spine (for altered LOC and neck

pain)

RESULTS
Sinus tachycardia (most of the time)
Aorta atherosclerotic, cardiac silhouette
enlarged, heavy mitral valve calcification.
Chronic bronchial thickening.
No acute brain process. Old right frontal lobe
infarct. Microvascular changes.
Small old basal ganglia lacunar infarcts. Mild
cortical atrophy and chronic small vessel
ischemia changes. No acute intracranial
process.
Moderate to severe multilevel degenerative
disc and facet changes greatest at C5-6. 2mm
anterior subluxation C7 on T1 probably related
to facet degenerative changes.

N4810 Clinical Paperwork Rev 11/6/13

6. Risk for unstable glucose level

Data to Support:
-Pt admitted for hypoglycemia
-Blood glucose monitoring AC/HS
-Pt on sliding scale for insulin lispro
-Inadequate intake r/t restraints and confusion
-Confusion
Interventions:
-Monitor blood glucose AC/HS
-Evaluate A1C for control over previous 2-3 months
-Administer insulin according to sliding scale.
-Monitor I&O
-Monitor for s/s of hypo/hyperglycemia
-Assess for cognitive changes that may have led to
admission for hypoglycemia
5. Risk for bleeding
Data to Support:
-Pt fell prior to admission
-Pt receiving heparin 5,000 units subQ and aspirin
-RBC: 3.36 (trending down)
-Hgb: 10.5 (trending down)
-Hct: 31.2(trending down)
-Ecchymotic skin on arms
Interventions:
-Monitor lab values (CBC, INR, PT, PTT)
-Monitor VS
-Monitor medications for bleeding risks
-Assess for s/s of bleeding (abdominal pain/swelling,

absent/decreased bowel sounds, light-headedness,

large area of deeply purple skin (ecchymosis),
increased HR, decreased BP
4. Anxiety:
Data to Support:
Pt. confused
-Previously on restraints
-Verbalizes fear about paying for lunch says she sees
her husband
-Keeps trying to get in and out of bed
-Fidgets and very restless
-Pt thinks she has things to do and places to be that arent
real.
Interventions:
-Ativan was prescribed but only as a single dose on
admission. May need new medication.
-Explain procedures. Use step-by-step directions
-Reassure patient as appropriate. Use relaxation
techniques and therapeutic communication.
-Encourage family participation (she seemed to really
relax when family was present)

Concept Mapping
7. Risk for Injury
Data to Support:
-Confused
-Previously on restraints
-Multiple medications
-Pt has a foley and a running IV (risk for tripping)
-Generalized weakness
Interventions:
-Fall protocol
-Aspiration protocol
-Pt has a sitter
-SCDs applied
-BS monitored and adjusted with medication (to avoid
hypo/hyperglycemia)
Chief Medical Diagnosis: Hypoglycemia
Priority Assessments:
LOC: she has been confused since admittance
VS: pt is on medications that have affected her
HR and BP
EKG: pt is on renal tele with frequently
irregular heart rhythm
I&O: pt has been on restraints and her some of
her electrolyte levels have been off
-Glucose levels: uncontrolled type 2 DM

Student Name: _____________

1. Acute Confusion
Data to Support:
-Hypoglycemia can cause confusion, however, it
has persisted even though her glucose levels are
now within range
-Patient Frequently only A&Ox2 or less
-Pt verbalized a need to have to pay for her lunch
using a lunch card when there is no lunch card
sin the hospital.
-Pt had a sitter due to her confusion
Interventions:
-Continually assess patient LOC and orientation
-Perform an accurate mental status exam
-Assess blood sugar (to make sure mental status
isnt due to a separate physiological alteration)
-Reorient pt as necessary
-Keep patient calm and relaxed
-Assist with ADLs. Use simple directions
-Pt was on Risperidal to help with confusion, but
was taken off because it was causing pauses in
her EKG

3. Imbalanced Nutrition: less than body requires

2. Decreased Cardiac Output
Data to Support:
Data to Support:
-Hx: abnormal heart sounds and HTN
-Pt. came in with hypoglycemia, which could have
- EKG showed tachycardia and some arrhythmias
been due to diet
-Pt went for an echocardiogram on 3/13/15 at 1300. I wasnt able to get
-Pt intake is limited, was on restraints
her Ejection Fraction
-Pt rarely drinks fluids unless told to.
-Clammy mottled skin
-Confusion
-HR: 110, SpO2: 95%, BP: 159/65
-Low Mg level (1.1)
-RBC: 3.36, Hgb: 10.5, Hct: 31.2
-Pt lost 10 lbs since admittance
Interventions:
Interventions:
-Assess heart sounds, rate, and rhythm. Assess lung sounds (monitor for
-Monitor I&O
s/s of HF)
and EKG
-Encourage fluids and food intake
Student-Monitor
Name:VS_________________________
-Monitor I &O
-1:1 feeder (sitter)
-Administer O2 as needed
-Pt reoriented frequently
-Apply SCDs
-Mg replaced
-Echocardiogram scheduled
- Calcium carbonate/vitamin D (caltrate 600+D) and
-Monitor lab values (CBC, Na, and Creatnine)
Ascorbic acid (vitamin C) administered
N4810 Clinical Paperwork Rev11/06/13

Problem Evaluation
Problem #
1

Evaluation of Patient Response

Pt fluctuated frequently between A&O x4 to A&Ox2 or less. When she was on Risperidal she was much more alert and oriented,
however, it was causing frequent pauses in her heart rhythm, so the doctor d/c the medication. Since the medication was d/c the
patient became much more confused and the sitter became frightened that she was hallucinating because of what she was saying.
The patient also kept trying to sit up and get out of bed, not realizing her own weakness/confusion. I went in to the room and took
like 15 minutes to sit and talk with the patient, reorient her, use therapeutic communication, reassured her as appropriate, and
repositioned her so that she was comfortable and relaxed. The patient seemed to respond well to this, because during the rest of the
shift she seemed a lot calmer and the sitter wasnt as worried. Family visits were encouraged, because when they were present the pt
seemed to be much more relaxed and oriented. A quiet and reduced stimulus environment was provided in order to keep the pt
relaxed. The pt may be experiencing some dementia, which was exacerbated by the episode of hypoglycemia. I made sure I
explained everything I was doing to the patient and gave her simple step-by-step directions. The pt seemed much more calm when I
explained what I was doing.
The pt was frequently tachycardic since her metoprolol was held. The doctor held the medication because every time it was
administered the patients HR would drop to the 50s and then after it wore off, would shoot back up into the 100s. So, the doctor
suspected the pt had sick sinus syndrome (SSS). The patients BP remained slightly high as did her HR, but there was no medication
prescribed yet to manage her HR appropriately. The pt didnt experience any adverse effects from these changes. SCDs were
applied and O2 wasnt needed. She was scheduled for an echocardiogram later on the second day, which may provide some answers
on the status of the heart and help make a plan for how to treat the client in the future (may need a pacemaker).
Since the pt was on restraints and because she is confused, her intake diminished slightly. So, now that she is out of restraints I
really encourage her to eat and drink fluids regularly. The pt seemed to respond well to this encouragement. A 1:1 feeder was
ordered, this was a way to closely monitor the pts intake. Her Mg was replaced and there was no s/s of hypo/hypermagnesmia
while I was caring for her. Supplements were administered. All electrolytes were WNL except for Mg, which was replaced.
The pt responded really well to the relaxation techniques and therapeutic communication that I used. As mentioned previously I
went in to the room and took like 15 minutes to sit and talk with the patient, reorient her, use therapeutic communication, reassured
her as appropriate, and repositioned her so that she was comfortable and relaxed. The patient seemed to respond well to this,
because during the rest of the shift she seemed a lot calmer and the sitter wasnt as worried. Family visits were encouraged, because
when they were present the pt seemed to be much more relaxed and oriented. Since the patient didnt have anything in her MAR for
anxiety, her behavior should be discussed with the doctor in order to see if something should be prescribed to help calm the patient.
This would also help limit her risk for injury, because she might not keep trying to get in and out of bed so frequently due to
agitation/confusion.
The patient has not shown and s/s of bleeding besides her lab values, which is a good sign. Her MRI,X-ray, and CT all were
negative for any signs of bleeding. Her bowel sounds were active, stomach was non-distended and without pain. Her arms were

N4810 Clinical Paperwork Rev11/06/13

ecchymotic but that could mostly be attributed to age and thin skin. The pt should just continue to be monitored for s/s of bleeding
and for any further decrease in her lab values (RBC, Hgb, Hct).
The patient responded well to all interventions because her glucose remained relatively stable since admission. Her blood glucose
level was medicated with insulin according to a sliding scale. The pt seemed to understand the need to monitor her blood glucose
levels. The pts confusion is what may have to led to her admission for hypoglycemia, so before discharge this should be addressed.
The pt remained free from injury since her admission. Fall and aspiration precautions were taken in order to prevent injury. The pt
was very confused, which also put her at risk for injury. She was frequently reoriented and a quiet environment was provided in
order to help with orientation/confusion. The sitter was an added precaution to prevent injury as well.

N4810 Clinical Paperwork Rev11/06/13

Student Clinical Self-Appraisal

EXAMPLE
Weekly (turn in with Care Plan/Map)
Student: Kaylee Blankenship Course N4810_____ Instructor: Sherri Brown
Instructions: Please evaluate your performance during clinical today using the following concepts:
Client Advocate
Critical Thinking
Self-Initiated
Professional Accountability
Leadership
Nursing Process

Professional Demeanor
Flexible
Communication/rapport
Coordinator of Care
Technical skills
Team Player
Organized
Educator
Well-prepared
Ability to Prioritize
Comprehensive Assessment
Knowledgeable

Areas of Strength Today: 3/13/15

Areas Needing Growth-Include plan of improvement

Self-Initiated/Leadership: This week I felt like I did a lot

of the pts coordinated care on my own. I was able to
bring things to the nurses attention that she did not
recognize.

Leadership: I think I still need work on my leadership

skills. As a student nurse I am not also super confident
in my skills and knowledge level yet, but I am
definitely making progress.

Ability to Prioritize: I used more of my time

management skills this week and became more
organized. One of my patients was on an insulin drip so
I had to really pay attention to my timing to make sure
that the blood sugars were on time.

Technical skills: I could perfect my skills a little more.

I am not always 100% on the steps of every procedure,
but that is why I check the policy and procedures.

Communication/rapport: I felt like I built rapport with

both patients. They looked forward to seeing me the next
day and felt comfortable asking me questions. I was able
to use therapeutic communication with the pt with
altered LOC. She was becoming agitated and I was able
to get her to relax without medication.

Critical thinking: I am always working to improve my

critical thinking skills. I am not always able to connect
all of the dots as far as labs, medications, diagnosis and
s/s are concerned. Each clinical experience helps to
hone these skills though.

Well-prepared: I felt really prepared this week. I made

sure I got a thorough history on each pt and came
prepared to take care of each pts needs.
Knowledgeable: I knew quite a bit about each patients
diagnosis already, but I did learn a lot about
documentation and critical thinking.
Instructor Comments:
I am so excited for you to move on out of the program You are an incredible student nurse and I love seeing you
grow. Your leadership skills will improve as you move out of nursing school. It is hard to grow in this area in
school. I love how you attacked your labs this time. You often gave a couple of reasons why lab could be altered
and one was always correct. Nice job!!!!

N4810 Clinical Paperwork Rev11/06/13

Students Name: Kaylee Blankenship Pts Initials: D.R.

Atrial rhythm: Regular or

Atrial Rate:

60 bpm

Irregular

Date: 3/13/15

Ventricular rhythm: Regular or

Irregular

Ventricular rate: 80 bpm

PR interval: 0.12 seconds

QRS interval: 0.08 seconds

QT interval: 0.4 seconds

Is AV conduction normal? (Y/N)______________ If not, why is it abnormal? sinus node isnt
firing correctly resulting in occasional junctional beats
P wave normal? (Y/N) Not every QRS has a p-wave
QRS complex normal? (Y/N) 0.08 seconds
Are all of the QRS complexes the same? (Y/N) ___________________
Are there premature beats? (Y/N) __________ , Atrial

or

ventricular

Interpretation of rhythm:
2 junctional beats present (4th and 8th complex)
Potential hemodynamic consequences of this rhythm and interventions for this rhythm:
Pt should be monitored for any further EKG abnormalities. Pt also has SSS, which can cause
quick fluctuations in EKG rhythms. Pt had medications, such as metoprolol and risperidone due
to the adverse side effects they were having on her heart rate and rhythm. No interventions are
needed at this time just closely monitor for any changes in current status.
N4810 Clinical Paperwork Rev11/06/13

Student Name: Kaylee Blankenship

Date:

3/20/15

Clinical Instructor:

Sherri Brown_

Instructions: Attach a copy of this form to the back of each of you Clinical Plan of Care/Maps for grading purposes.
Grading Rubric:
1.

Patient Data includes:

a. Health history
b. All blanks and/or issues are addressed

20 points possible ____20_

2.

Each medication includes:

a. Name
b. Rationale
c. Side effects
d. Nursing implications-specific to this patient

20 points possible ___20__

3.

Lab Diagnostics
a. Test
b. Results
c. Implications & Teaching

10 points possible _10____

4.

Problem Identification includes

20 points possible __20___
a. Correctly lists individualized needs
b. Correctly identifies problems
c. Problems are prioritized and numbered, each problem in priority of importance
d. Map includes at least five physiological problems, discharge planning and patient education
e. Each problem includes:
i. Nursing diagnosis
ii. Data to support
iii. Medication
iv. Nursing treatment (interventions)

5.

Planned interventions includes

a. Interventions appropriate
b. Correctly prioritizes interventions
c. Assessments performed
d. Communication
e. Patient teaching
f.
Discharge planning

10 points possible _10____

6.

Evaluation of Interventions includes

a. Evaluates physical interventions
b. Evaluates teaching

10 points possible ____10_

7.

a.
b.

10 points possible ___10_

Priority Assessments are appropriate to diagnoses

Clinical Paperwork is complete

N4810 Clinical Paperwork Rev11/06/13

Total Points

____100_________/100 = ____%

N4810 Clinical Paperwork Rev11/06/13