Student Name: Clinical Assigned Unit:

Date: 12/8/2017 NCCU

Age: Gender: Admission date: Resuscitation Status: FULL
76 F 12/06/2017
@1702
Admit weight: Height: 157.5
114 kg cm
Reason for Hospitalization:
CVA - bilat (poss due to a-fib), dissection of R femoral artery, low hcg/hct

Past medical history:

DM2

Past surgical history:

None

History of present illness:

CVA on 12/06/2017, went under surgery to retrieve clot and R femoral artery was accidentally
dissected. A stent was placed and artery repaired. Surgery was repeated on L side successfully. Pt
has no noticeable facial droop but has some function loss in her hands and feet. Pt seems to has
some dysphagia,

Clinical Preparation Form N414

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 4.5-13.5 11.58
(WBC)

Red blood cells (RBC) 4-5.2 2.95

Hemoglobin (Hgb) 11.5-15.5 8.5

Hematocrit (Hct) 34-45 25

TEST NORMAL VALUES DATE/TIME RESULT/ REASON FOR ABNORMAL VALUE AND
RECENT EFFECT OF ABNORMAL VALUE
TREND (POTENTIAL SYMPTOMS)
Platelets 150-400 174

Prothrombin time (PT) 15.1

International 1.2
normalized ratio (INR)

Partial thromboplastin 26
time (PTT)

Sodium (Na) 137-146 140

Potassium (K) 3.4-4.7 3.8

Chloride (Cl) 102-111 114

Glucose 60-115 78

Hemoglobin A1C

Cholesterol

Blood Urea Nitrogen 7-19 13

(BUN)

Creatinine 0.27-0.73 0.92

Pre-albumin

Albumin
Calcium (Ca) 8.8-10.2 7.2

Phosphorus 2.5-4.5 2.4

TEST NORMAL VALUES DATE/TIME RESULT/ REASON FOR ABNORMAL VALUE AND
RECENT EFFECT OF ABNORMAL VALUE
TREND (POTENTIAL SYMPTOMS)
Bilirubin 0.1-1.2 0.7

Alkaline phosphatase

ALT (alanine
aminotransferase)

AST (aspartate
aminotransferase)

CK

CK MB

Troponin

B-natriuretic peptide
(BNP)

Other Labs 2.1-2.8 2.4

Mag

Arterial Blood Gas:

pH 7.35-7.45 7.319

pC02 35-45 48.4

PaO2 >79 117

HCO3 22-28 24
Oxygen saturation 94-100 97

Lactic Acid 0.5-1 0.4

Allergies:
Allergies: Type of Reaction:
NKDA

Standards of Care:
NO YES INTERVENTIONS ORDERED
DVT prophylaxis x scd
Stress ulcer prevention x turns
Ventilator-associated pneumonia x
(VAP)

Intake/Output:
Diet Order: Restrictions: Precautions: Gag Reflex Intact:
Dysphagia 3 Thick Liquids YES

Appetite (good, fair, Breakfast % Lunch % Dinner %

poor): 100

Total Oral Fluid Intake: Total IV Fluid Intake: Total Output:

250 500 200
Enteral Feeding: Rate: Type of enteral feeding tube:
125/discontinued x

Problems swallowing YES NO

Problems chewing YES NO
Dentures - lower YES NO
Needs assistance with YES NO
feeding

Intravenous Therapy:
IV Fluid: Type of Solution IV rate Indication
NS isotonic 125 Fluid
maintenance/resusitation
IV Fluid: Type of Solution IV rate Indication
Peripheral Access Site Assessment YES NO
IV site and catheter gauge: IV dressing dry, no edema, redness of x
R AC 18 site

IV site and catheter gauge: IV dressing dry, no edema, redness of x

site
RFA 18
IV site and catheter gauge: IV dressing dry, no edema, redness of x
L UE 18 site

Central Access (CVC) Site Assessment YES NO

Central line site: # of lumen: Alcohol caps present (if used) x

Indication for line: Dressing dry and intact

Central Access (CVC) Site Assessment YES NO

Central line site: # of lumen: Alcohol caps present (if used) x

Indication for line: Dressing dry and intact

Elimination:
Last bowel movement: 12/7

Constipation YES NO
Diarrhea YES NO
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 None
Use of assistive devices:
Cane YES NO
Crutches YES NO
Walker YES NO
Crutches YES NO
Prosthesis YES NO

Physical Assessment Data:

BP: Temp/Method: Pulse: Respiratory rate: SpO2:
127/94 36.9 - Temporal 89 20 97

Neurological:
Glasgow Coma Assessment *Describe any abnormalities in box below
Eye opening response Score 4
Verbal response Score 5
Motor response Score 6

Pupil Assessment
Right pupil size Size: 3
Left pupil size Size:3
PERRLA YES: X NO:

LOC: Describe orientation

Able to follow commands YES NO
Grip equal, bilateral YES NO Stroke, some weakness
Sensation intact to all extremities YES NO
Speech clear YES NO
Sensory deficit (hearing, vision, taste, YES NO
smell
Dizziness, vertigo YES NO Dizziness
Use of assistive device (glasses, hearing YES NO Specify:
aids)
**Additional detail required in box for abnormal findings**

Cardiovascular:
Pulses (radial, pedal) palpable, equal, YES NO R pedal pulse 1+
strong
Normal heart tone (S1, S2), regular YES NO
Capillary refill (<3 seconds all extremities) YES NO R LE >3sec
Extremity temperature warm to touch, YES NO R LE cooler to touch
bilateral upper and lower extremities
Edema presence YES NO Specify location and degree 0-4 scale
1
Pacemaker YES NO Specify type (temporary, permanent)

**Additional detail required in box for abnormal findings**

Respiratory: Additional detail

Respiration pattern regular without YES NO
effort
Use of accessory muscles YES NO
Productive cough YES NO
Sputum production YES NO Description of sputum:

Nonproductive cough YES NO

Lungs clear to auscultation, all fields YES NO Diminished lower
Use of oxygen YES NO Specify mode and flow rate of oxygen:

Oxygen humidification YES NO

Smoker YES NO Specify current or past hx:

Ventilation
Is patient on YES NO
ventilator?
Ventilator mode
FiO2
PEEP
Rate
Tidal volume
Type of airway tube
Indication

Is patient requiring Bipap YES NO Specify type:

or CPAP?
FiO2
IPAP* mmH20
EPAP* mmH20
Rate (For Bipap ONLY)
IPAP-Inspiratory positive airway pressure; EPAP-Expiratory Positive Airway Pressure

Gastrointestinal: Additional
detail
Abdomen soft, nontender, all YES NO
quadrants

Bowel sounds present x4 quadrants YES NO Specify: active, hypoactive, absent

Nausea YES NO
Vomiting YES NO Description:

NG tube YES NO Describe drainage color, amount, consistency,

location of tube:

Problems swallowing YES NO

Problems chewing YES NO
Dentures YES NO Lower dentures
Needs assistance with feeding YES NO
Stool YES NO Describe amount, color, consistency:

Ostomy YES NO Describe type of ostomy, stoma site and

output:

Additional GI tubes YES NO Specify:

**Additional detail required in box for abnormal findings**

Urinary:
Continent, voiding without difficulty YES NO
Incontinent YES NO Interventions:

Foley catheter, patent, down drain, YES NO

secured to leg
Urine clear, light yellow to amber, no YES NO
odor
Additional GU tubes YES NO Specify

**Additional detail required in box for abnormal findings**

Musculoskeletal:
Normal muscle tone without weakness YES NO weakness
Able to transfer independently YES NO
Purposeful movement, all extremities YES NO
Normal skeletal alignment/structure YES NO
Altered gait YES NO Specify
Unable to stand and walk
Orthopedic device (cast, splint, brace) YES NO Specify

Fall risk YES NO Specify rationale

IV, recent stroke, medication
**Additional detail required in box for abnormal findings**

Skin:
Skin dry, intact, color within YES NO
patient norm
Mucous membranes moist YES NO
Evidence of skin breakdown YES NO Specify location:

Rashes or bruising YES NO Specify location:

R Groin bruise
Sutures, staples, steri-strips YES NO Specify:

Wound drainage YES NO Describe drainage:

Wound drain YES NO Specify:

Braden Score:

**Additional detail required in box for abnormal findings**

Psychosocial and Cultural

Marital status/children/social support:
Married, Family (daughter) visiting
Religious preference: Unknown
Occupation:
None

Pain
Pain Score ____6_____ out of 10 (10 being severe pain, 1 minimal pain)
Characteristics
Sharp
Onset On palpation

Location R groin, R leg

Duration Ongoing

Exacerbation Palpation

Radiation None

Relief Meds, rest

Associated Recent surgery

symptoms

Medication List: For all PRN and scheduled meds please include the following
 Trade name
 Generic name
 Mechanism of action (how does the drug work)
 Dose/route/frequency
 Indication for the drug (why is the patient receiving the medication)
 Major side effects
 Nursing implication
 Special precautions

Pathophysiology: Provide a detailed description of the patient’s disease process

including clinical signs and symptoms associated with the disease

Stroke: caused by an embolism that makes its way to the brain where it blocks arterial
flow thus causing ischemia, and cell death. Signs and symptoms include one or two
sided weakness, aphasia, drooping facial features, confusion, ataxia, blurred vision,
headaches.
 Expand | Hide
Current Scheduled Medications

Obtain a dietary Hx
(esp with fat
consumption, Assess
Rhabdomyolysis,
atorvastatin triglyceride and
10 mg, Oral, abd cramps,
(LIPITOR) Hyperlipidemia cholesterol, monitor
Bedtime diarrhea, flatus,
tablet 10 mg Liver fx tests, if pt
rashes, constipation,
develops muscle
tenderness monitor CK
levels.
Assess for SS of
1-7 Units,
insulin lispro hypoglycemia as well
Subcutaneous, 4
(HumaLOG) Hypoglycemia, as hyperglycemia,
times daily with Hypoglycemia
injection 1-7 anaphylaxis, monitor body weight
meals and
Units periodically, monitor
bedtime
for SS of anaphylaxis
GI Bleeding,
Stevens-Johnsons
Check for bruising,
aspirin tablet 325 mg, Oral, syndrome, toxic
MI, bleeding, Assess for GI,
325 mg Daily epidermal
Hct
necrolysis,
anaphylaxis,
Not to be given with
acute abd pain or with
Stool Softener, Abdominal
bowel obstruction,
bisacodyl Constipation, cramping, nausea,
5 mg, Oral, Daily ensure pt has adequate
(DULCOLAX) (from pain meds, fainting, diarrhea
PRN fluid intake prior to
EC tablet 5 mg also possibly post Fluid and electrolyte
administering, teach
surgical) loss
about other sources of
fiber
Assess pt for abd
distention, presence of
docusate-senna
Constipation bowel sounds, bowel
(SENOKOT-S) 1 tablet, Oral,
(probably from px Cramping, diarrhea, function, assess color,
8.6-50 mg per Twice daily PRN
meds) amount and
tablet 1 tablet
consistency of stool
produced.

Current Continuous Medications Expand | Hide

sodium chloride Assess BP, fluid

Intravenous, 125 Fluid/electrolyte HTN, Edema,
0.9% (NS) status, Chem
mL/hr, Continuous replacement Pulmonary edema
infusion Labs
Current PRN Medications Expand | Hide

Start Ordered Stop

Intravenous,
Continuous
Loading Dose:
0.4 mg
Demand Dose:
0.2 mg
HYDROmorphone in Respiratory Depression, Sedation, Assess BP, Pulse,
Basal Rate: 0 Analgesic
NS (DILAUDID) PCA Confusion, Hypotension, Constipation Respiratory, Bowel Fx
mg/hr
Lockout
Interval: 10
Minutes
One Hour Dose
Limit: 1 mg
Leukopenia, neutropenia,
Assess liver fx tests,
650 mg, Oral, pancytopenia, anemia,
acetaminophen assess skin for SS of
Every 6 hours analgesia hypoglycemia, hypokalemia,
(TYLENOL) 650mg stevens-johsnons
PRN hypomagnesemia, hypoxia,
syndrome, assess px
pulmonary edema, stridor