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Laboratory Values: Complete the table with applicable lab values, for the
results/trend indicate if value is increased or decreased from previous result
TEST NORMAL VALUES DATE/TIME RESULT/ REASON FOR ABNORMAL VALUE AND
RECENT EFFECT OF ABNORMAL VALUE
TREND (POTENTIAL SYMPTOMS)
White blood cells 4,500 to 11,000 2/8/19 18.1 (high) Due to sepsis, body is trying to fight of
(WBC) 1046 the infection causes fevers
Red blood cells (RBC) 4.2 – 5.4 2/8/19 1.35 (low) Due to cardiogenic shock, inability of the
1046 heart to pump sufficient blood can cause
hypoxia
Hemoglobin (Hgb) 12-16 2/8/19 4.0 (low) Due to fluid overload and decreased RBC
1046 Can cause hypoxia
Hematocrit (Hct) 35-47 2/8/19 13.1 Fluid overload and blood loss from line
1046 (decreased) placements and placement of impella
Can cause fatigue
TEST NORMAL VALUES DATE/TIME RESULT/ REASON FOR ABNORMAL VALUE AND
RECENT EFFECT OF ABNORMAL VALUE
TREND (POTENTIAL SYMPTOMS)
Platelets 150,000-450,000 2/8/19 81 (low) Due to blood loss from line placements
1046 Can also be lower b/c pt lived in low
elevation
Can cause blood loss
Prothrombin time (PT) 9.5 – 12 sec 2/8/19 27.3 (high) Due to liver failure
1046 Can lead to fluid buildup in legs and
abdomen, can also cause jaundice
International <1.0 2/8/19 2.4 (high) Blood is clotting slower due to low PLTS
normalized ratio (INR) 1046 Can lead to blood loss
Partial thromboplastin
time (PTT)
Sodium (Na) 135-145 2/8/19 151 (high) Due to fluid retention, causes edema
1046
Potassium (K) 3.5 – 5.0 2/8/19 4.6 Normal, K excites the heart with both
1046 high and low values. Can cause
dysrhythmias
Chloride (Cl) 97 - 107 2/8/19 117 (high) Due to dehydration and kidney failure
1046 Can cause acidosis
Hemoglobin A1C
Cholesterol
Blood Urea Nitrogen 10-20 2/8/19 34 (high) Due to renal failure and heart failure
(BUN) 1046 Can have symptoms of weakness and loss
of appetite
Creatinine 0.7 – 1.4 2/8/19 1.15 High side of normal due to kidney
1046 dysfunction and can have symptoms of
decreased urine output
Pre-albumin
Calcium (Ca) 8.6 – 10.2 2/8/19 7.6 Normal, Can be due to CKD, Calcium
1046 calms and affects nerves and muscles. S/s
of high: can cause bone weakness, n/v
and stomach upset
S/s of low: confusion, memory loss and
muscle cramps
Phosphorus 2.7-4.6 2/8/19 3.5 Normal, Can be due to CKD. S/S of high:
1046 joint pain, muscle pain, diarrhea
S/s of low: irregular breathing, fatigue
and loss of appetite
TEST NORMAL VALUES DATE/TIME RESULT/ REASON FOR ABNORMAL VALUE AND
RECENT EFFECT OF ABNORMAL VALUE
TREND (POTENTIAL SYMPTOMS)
Bilirubin 0.3 – 1.0 2/8/19 3.4 (high) Can be due to anemia, can cause jaundice
1046
ALT (alanine 8 - 35 2/8/19 531 (high) Due to liver disease, can cause jaundice
aminotransferase) 1046 and weakness
CK
CK MB
Other Labs
Lactic Acid 0.5 – 1 2/8/19 17 (high) Indicator of sepsis, can cause muscle
1153 weakness.
Allergies:
Allergies: NKDA Type of Reaction:
Standards of Care:
NO YES INTERVENTIONS ORDERED
DVT prophylaxis X ASPRIN
GI Stress ulcer prevention X Pantoprazole
Ventilator-associated pneumonia (VAP) X Chlorhexidine
Intake/Output:
Diet Order: Restrictions: Precautions: Gag Reflex Intact:
NPO NPO Aspirations Does not have a gag reflex
**For ALL pressure lines: Pressure bag inflation volume, type of fluid, and confirmation of volume
remaining, and zeroing of transducer is REQUIRED
Elimination:
Last bowel movement: Pt did not have
a BM while in the hospital. Additional comments for abnormal assessment findings:
Constipation YES NO Soft, nontender, nondistended, symmetrical, bowel
Diarrhea YES NO sounds absent in all 4 quadrants.
Flatus YES NO
Incontinence-bowel YES NO
Urinary hesitancy YES NO
Urinary frequency YES NO
Burning YES NO
Incontinence-urinary YES NO
Unusual odor YES NO
Activity:
Type of activity ordered: Ability to walk (gait): Morse Falls scale score:
Bedrest Unable to walk 35
If vasopressors are ordered for the patient, note desired goal used for
titration. MAP goal >65
How did the patient respond to the medication(s)?
Poor response, maxed out on NE & Vasopressor.
Neurological:
Glasgow Coma Assessment *Describe any abnormalities in box below
Eye opening response Score 0
Verbal response Score 1
Motor response Score 1
For any GCS <15, please note specific criteria that was abnormal.
Pt is unresponsive to any stimuli, does not have spontaneous eye opening or
any movement.
Pupil Assessment
Right pupil size Size: 2mm
Left pupil size Size: 2mm
PERRLA YES: NO:
Sluggish
Pt is unresponsive.
Cardiovascular:
Pulses (radial, pedal) palpable, equal, strong YES NO Palpable, equal, weak
Normal heart tone (S1, S2), regular YES NO
Capillary refill (<3 seconds all extremities) YES NO
Extremity temperature warm to touch, YES NO
bilateral upper and lower extremities
Edema presence YES NO Specify location and degree 0-4 scale
In all extremities +4
Pulmonary Artery catheter (Swan) YES NO Transducer zeroed, pressure bag checked for
fluid/pressure level, no air present
Pt is on ventilator.
Ventilation
Is patient on ventilator? YES NO
Ventilator mode CMV
FiO2 60%
PEEP 8
Rate 28
Tidal volume 270
Type of airway tube ETT
Indication Respiratory distress secondary to pulmonary edema
How is the patient tolerating the therapy either mechanical or non-invasive ventilation?
PT was tolerating well, not panicking or showing signs of resistance.
For mechanical ventilation:
o Was the patient sedated on a continuous IV infusion (s)? List ALL infusions ordered
for sedation.
o Was the patient restrained either with physical restraints or chemically with
paralyzing medications?
Physical restrains
Additional detail
Gastrointestinal:
Abdomen soft, nontender, all quadrants YES NO
Nausea YES NO
Vomiting YES NO Description:
Pts body was shutting down, bowels were absent in all quadrants.
Urinary:
Continent, voiding without difficulty YES NO Decreased urine output due to renal failure
Incontinent YES NO Interventions:
What additional assessments and/or interventions were completed to help in the prevention
of the development of a CAUTI (Catheter associated urinary tract infection)?
-Sterile technique completed upon insertion
-Maintenance of a closed urinary drainage system
-Daily cleansing of the urethra
Musculoskeletal:
Normal muscle tone without weakness YES NO Decreased muscle tone
Able to transfer independently YES NO Pt is unresponsive
Purposeful movement, all extremities YES NO Pt is unresponsive
Normal skeletal alignment/structure YES NO
Altered gait YES NO Pt is not ambulating
Was physical therapy/occupational therapy ordered on the patient? No, due to impella in
groin.
If present, describe the exercises/activity performed? N/A
Did the patient tolerate the activity? N/A
Is there a decline or improvement in the patient’s ability since beginning therapy? N/A
Based upon your assessment findings, is your patient at risk for developing skin breakdown?
Yes, pt had rooke boots to prevent breakdown and to improve circulation.
What additional preventative measures have been implemented or would you anticipate
using to preserve the patient’s skin integrity? I would anticipate changing the pts position
every 2 hrs. I would also make sure that her skin is kept dry to prevent breakdown.
Skin dry, intact, color within patient norm YES NO Dry, intact, pale
Mucous membranes moist YES NO Dry
Evidence of skin breakdown YES NO Specify location:
Religious preference:
Jehovah’s Witness
Occupation: Retired
Was any family/friends present during your shift? Yes, all family members were present.
Did the family/friends receive any updates on status from the care team (MD, PA, NP)? Yes,
the family had a family meeting with the MD at 11am.
Was there any specific teaching given (family/friend/patient)? During the conference the MD
first explained the situation, gave rationales and answered all the family’s questions. He used
vocabulary that was simple enough for the family to understand.
How was the information received? Verbally, through an interrupter as most of the family
was Spanish speaking.
Pain
Pain Score 0 out of 10 (10 being severe pain, 1 minimal pain)
Characteristics Face was relaxed and neutral, absent of movements.
Onset N/A
Location N/A
Duration N/A
Exacerbation N/A
Radiation N/A
Relief N/A
Clinical signs/symptoms: A rapid, thready pulse; a narrow pulse pressure; dyspnea; tachypnea;
inspiratory crackles; distended neck veins; chest pain; cool, moist skin; oliguria; and decreased
mentation.
Complications (possible or actual): Arterial blood gas analysis can reveal a decreased PaO2 and
causes respiratory alkalosis. Hemodynamic findings include a systolic blood pressure less than
85 mm Hg, a mean arterial blood pressure less than 65 mm Hg, a cardiac index less than 2.2
L/min/m2, and a PAOP greater than 18 mm Hg.