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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. N4810 Clinical Paperwork Rev 11/6/13

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Page 1: ICU Patient

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 expe-rience. 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.

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CSU, STANISLAUS B.S.N.CLINICAL PLAN OF CARE

Patient Data

Student: Kaylee Blankenship Date of Care: 4/16/15-4/17/15 Room Number: S3323 Code Status: FULL

Pt. Initials: J.R. Gender: Male Age: 19 Height:5’8” Weight:82.8 kg (182 lb 8.7 oz) BMI: 31.04 Spirituality: Ø Ethnicity: Caucasian

Admitting Diagnosis: MVC (Multiple rollover, pt was ejected 30 ft from the vehicle), SDH, SAH, C-7 fracture, bilateral pnuemothoraces, left femur fracture, IFT, SJGHVital Signs: Temp 101.3 F (38.5 C) HR 91 RR 17 B/P 124/58 O2 Sat 99% Pain Scale & Scale Type 10/10 (numeric scale)History related to this admission: Ø Past Medical History: Ø Admit Date: 4/6/15 POD: 1Surgical History & Date: Ø MD(s): Barry (attending)

Diet: orogastric tube feedings (NPO for procedure), normally Pivot 15 @ 60 ml/hr Activity: BedrestFoley: Undwelling urethral cath (w/core temp probe Feeding Tube & Rate: Naso/oral tube (mouth) Pivot 1.5 continuous initial 20 ml/hr, advancement rate 20 ml/4hr, goal 60 ml/hr, water flush for hydration 175 ml (6x/day) Advance Directive: Yes ________ No X Drains/ Tubes: EVD (external ventricular drain), chest tube left anterior 3 rd intercostal space, chest tube right anterior 3 rd intercostal space Isolation: Ø VS Freq: q15 mins (ICP check) Glucose Monitoring: Ø DVT Prophylaxis: SCD’s (right leg only)Vascular Access: PCA/Epidural: Ø (Fentanyl drip) Telemetry & Rhythm: 5-lead (normal sinus rhythm)IV Site: central line-triple lumen (subclavian) IV Solution & Rate: (multiple solutions running-see medications list)Safety Considerations: aspiration, bleeding, seizures, fall, contact Restraints: soft wrist restraints bilaterally Dressing Changes & Frequency: left posterior thigh (trauma), left lateral knee (trauma), left anterior thigh, left lateral ankle abrasion, right medical ankle abrasion, right medial knee (trauma), left cheek abrasion, right anterior knee (trauma), right lower arm abrasion, left medial calf (trauma), traction LLE (skeletal 15 lbs), cervical spine collar (daily care/change) Labs for day of clinical: BMO with GFR routine q12hr, creatinine routine q48hr while on vancomycin, Mg routine prn after Mg replacement, K routine (1hr post-replacement), vancomycin trough routine, CBC with automated differential routine daily am, CBC with automated differential routine q12hr Scheduled Procedures: CT scan, Intramedullary ROD fixation of left femur with irrigation and debridement of left thigh and left knee lacerations Procedures done this admission: craniotomy, evacuation of subdural hematoma and placement of ventriculostomy drain (4/7/15), antegrade femoral nail, incision and drainage of knee laceration (4/16//15) Oxygen: ET tube-ventilator at 30 % concentration Respiratory Treatment: albuterol via nebulizer Vent Settings: Tidal volume 650 ml, spontaneous 429 ml, vent mode volume SIML+PS, pressure support 10 cmH2O, PEEP 5 cmH2O, rate set 12 Advanced Hemodynamic Monitoring & Values: Arterial line B/P 104/79, MAP 91 mmHg, CVP 13 mmHgIV Drips Medications Dosage & Rate: Fentanyl drip 250 mcg/hr, 25 ml/hr, 10 mcg/ml Phenylephrine drip 110 mcg/min, 33 ml/hr, 0.2 mg/ml

Propofol drip 50mcg/kg/min, 25.6 ml/hr, 10 mg/ml

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MedicationGeneric & Trade Name Dose,

Route, Frequency

Mechanism of ActionClassification

Patient-Specific Rationale Nursing Considerations(Assessment implications, side effects, reasons to hold

med, administration rate, etc…)Acetaminophen (Tylenol)

160 mg/5 ml oral solution via OG tube q8hr prn

Analgesic, antipryretic;synthetic nonopioid p-aminophenol derivative

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.

For mild pain 1-3 or temp above 37 degrees C as indicated on MAR. Pt has an infection

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.

Acetaminophen (Tylenol)

650 mg suppository q8hr prn

“ ” For mild pain 1-3 or temp above 37 degrees C as indicated on MAR. Pt has an infection

“ ”

Albuterol

0.083% neb solution 2.5 mg q4hr RT

Bronchodilator; sympathomimetic/anticholinergic

Action: Albuterol produces bronchodilation by relaxing the bronchial smooth muscle through beta–2 receptor stimulation. Ipratropium antagonizes action of acetylcholine on the bronchial smooth muscle in the lungs, causing bronchodilation.

Promote lung function while on best rest Side effects:Blurred vision, dry mouth, urinary retention, back pain, upper respiratory tract infection.

Considerations:Monitor Potassium levels. Do not give med if levels are not WNL. Monitor BP. Stay alert for sensitivity reactions. Pt teaching on symptoms of hypersensitivity reaction symptoms. Instruct pt to notify prescriber if dosage no longer provides relief. Advise pt to limit intake of caffeine.

Bacitracin/polymyxin b (polysporin)

Topical ointment bid

Topical anti-infective

Action: Interferes with bacterial protein synthesis for skin infections.

Applied to the patient’s many abrasions in order to fend off possible infections.

Side effects: Rash, urticarial, scarring, redness

Considerations:-For external use only-Assess allergic reaction (i.e. burning, stinging, swelling, redness)-Evaluate therapeutic response (i.e. decrease in size or number of lesions)

Bisacodyl (Dulcolax) Laxative; Stimulant As needed for constipation if docusate, Side effects: Abdominal colic, abdominal discomfort,

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LABORATORY DATA

LABS Normal Range(Fill in Hospital Norms)

RESULT 14/14/150500

RESULT 24/15/15

0450

RESULT 34/16/15

0400

Reason for abnormal lab values r/t diagnosis & nursing implications

CBC WBC 4.0-11.0 K/uL 18.7 20.7 18.3 Pt’s level has remained high due to a number of

reasons including infection from multiple injuries sustained from a MVA, stress, and pain. The patient has been running a fever of about 39.0 degrees C. He was prescribed Zosyn and vancomycin IV in order to treat the infection. Monitor for s/s of worsening infection including fever, chills, fatigue, and a further increase in WBC count. His many wounds should also be monitored for s/s of infection including redness, swelling, or warmth around the wound site.

RBC 4.40-6.0 M/uL 3.21 3.21 3.25 This patient’s level has remained low in the 3.2 range. This may be due to all of the blood he lost upon admission. His body is still recovering from the blood loss and he still had 2 chest tubes in and wound vacs in a couple of his deep wound sites. The pt should be monitored for s/s of hemorrhage including light-headedness, large area of deeply purple skin (ecchymosis), increased HR, decreased BP.

Hemoglobin 13.5-18.0 g/dL 9.3 9.3 9.4 This patient’s levels have remained low since his admission. As menitioned in the explaination above, this could be sue to his body still recovering from the blood loss related to his injuries from the MVA. The pt should be monitored for s/s of hemorrhage including increased HR, decreased BP, oxygen saturation, RR, and excessive bloody drainage from chest tubes or wound vacs.

Hematocrit 40-52% 27.8 27.9 28.3 This patient’s levels have remained low since his admission. As mentioned in the explanation above, this could be sue to his body still recovering from the blood loss related to his injuries from the MVA. The pt should be monitored for s/s of hemorrhage including increased HR, decreased BP, oxygen saturation, RR, and excessive bloody drainage from chest tubes or

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wound vacs.PLT COUNT 150-400

K/uL385 428 503 The level has been trending upwards possibly

indicating hemorrhagic anemia or from trauma and major blood loss. Individuals with this problem may be at risk for excessive clotting due to increased platelets, but they may have bleeding problems because the platelets may bot function properly. Monitor pt for s/s of blood clots including seizures, shortness of breath, discoloration/swelling of extremities.

WBC DIFFNEUTROPHIL % 49-74% 83 80 82 The patient’s levels have been high which could be due

to trauma, physical stress, and infection due to injuries sustained from a MVA. The patient has been running a fever of about 39.0 degrees C. He was prescribed Zosyn and vancomycin IV in order to treat the infection. Monitor for s/s of worsening infection including fever, chills, fatigue, and a further increase in WBC count.

LYMPHOCYTE% 26-46% 6 9 6 The pt’s levels have remained low, which could point to lymphocytopenia. This lower level could also be attributed to the fact that he lost a lot of blood due to injuries he sustained from a MVA, so he body may be trying to reccoperate still and make more lymphocytes. This lower level also makes him more susceptible for infection so he should be monitored for further s/s including increased HR, decreased BP, oxygen saturation, RR, and excessive bloody drainage from chest tubes or wound vacs.

CHEMISTRYSodium 136-145

mmol/L140 138 138 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 cramps, seizures, coma, and signs of heart failure. Continue with IV fluids and monitor pt’s I&O.

Potassium 3.5-5.1 mmol/L 3.7 3.8 4.1 The patients value is within normal limits, however, due to his current condition he is still receiving Potassium Chloride replacement via IV for 4.1 and lower. Replacement is based on his level, which is why he has labs drawn twice daily in order to closely monitor. Monitor pt for s/s of hypokalemia such as muscle aches, abnormal weakness, arrhythmias, diarrhea, and nausea and vomiting. Also watch for s/s of hyperkalemia including abnormal heart rhythms, decreased heart rate, and weakness. Know which meds to hold if levels are not WNL.

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Glucose 70-99 mg/dl 124 116 102 His glucose level has been slightly high which could be attributed to his infection and trauma. However, it isn’t high enough to need intervention with medication or diet. Continue to monitor level and assess pt for s/s of hyperglycemia (frequent urination, increased thirst, blurred vision and headache) and hypoglycemia (headache, tremors, fatigue, weakness).

Calcium 8.2-10.2 8.0 8.0 8.4 This level was slight ly low and then rose to be WNL. This could be due to malabsorption (less calcium is available in the blood), or he may not have been getting enough in his diet through his OG tube. Monitor the pt for any s/s of hypocalcaemia including numbness, muscle cramps, and irritability.

Magnesium 1.8-2.4mg/dl 1.8 2.2 2.1 WNL

4/9/15- 0410 4/10/15- 0405ABG(FIO2 + device) 40.0 30.0 His first group of data on 4/9

indicates that the patient was experiencing respiratory alkalosis. His pH was high, his PCO2 was low and his bicarb was almost WNL, which is indicative of this disorder. His vitals would have shown tachypnea, anxiety, and rapid/deep respirations.

His levels from 4/10 indicate homeostasis. The pt’s pH, PCO2 and bicarb were all WNL.

pH 7.35-7.45 7.474 7.435PO2 80-100

mmHg98 118

PCO2 35-45 mmHg 27.9 38.2Bicarbonate 22-26 mEq/L 20.0 25.1Oxygen Saturation 93-100% 97 98

DIAGNOSTIC DATA Student Name: ____________________

Test ResultsECG Typically normal sinus rhythm, however, attached

picture of ECG illustrates sinus tachycardia.Chest X-ray Small bilateral pneumothoracesLeft Ankle X-ray Normal, no fracturesRight Ankle X-ray Normal, no fracturesLeft femur X-ray Comminuted mid femoral fracture

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Right Knee X-ray Normal, no fracturesCT-abdomen No hematoma. Edematous stranding

perivascular space of left thigh. Potential hematoma given open fracture.

CT-brain Right acute subdural hematoma up to 10 mm. Small left bilateral subdural hematoma up to 6 mm. Small subarachnoid hemorrhage. Small left frontal intraparenchymal hemorrhage contusions.

CT-facial sinuses Increased sinusitis. No facial bone fractures. Small pnuemocephalus.

Concept Mapping

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3. Decreased Intracranial Adaptive CapacityData to Support: -Pt had craniotomy on 4/7/15-SAH, SDH-EVD in place-ICP greater than 10 mmHg on occasionInterventions: -Check ICP readings q15mins-Maintain pt in proper position for ICP reading-Make sure EVD measures 3 marks out from scalp-HOB elevated at least 30 degrees-Ensure proper sedation-Maintain normothermia and adequate oxygenation-Limit ET-tube suctioning to two passes-Admin Mannitol IV based on ICP readings-Monitor EVD for abnormal drainage.

4.Altered Nutrition/Fluid and Electrolyte ImbalanceData to Support:Pt NPO for surgeryWeakness, OG TubeAnemic RBC 3.25, Hgb= 9.4, Hct= 38.3

5. Acute Confusion: Data to Support: -Pt sedated for last 2 weeks-Pt. only occasionally able to follow simple commands when sedated-When propofol was discontinued the pt became more alert/agitated and though his ability to follow commands increased, he was still very confused, which is why he was fighting us.Interventions:-Continually assess patient LOC and reorient -Perform an accurate mental status exam.-Check pupils-Reorient pt as necessary-Keep patient calm and relaxed-Admin Fentanyl/propofol to maintain adequate

Chief Medical Diagnosis: MVC (Multiple rollover, SDH, SAH, C-7 fracture, bilateral pnuemothoraces, left femur fracture

Priority Assessments: VS: pt is on numerous meds and has a craniotomy with a shunt, it is important to keep his VS WNLICP q 15 minsPain/sedation , LOCLungs sounds/suctioningDressing changes dailyCirculation: pt had skeletal traction, and bilateral wrist restraints I&O

1. Ineffective Breathing patternData to Support: -Pt is intubated and on a ventilator due to brain trauma-Breath sounds clear, but slightly diminished-Respirations increased as pt came off of sedation. RR became shallow and tachypnic.-Had to inform pt to calm down and take big, deep breaths in order to avoid hyperventilation. Interventions:-Administer Albuterol tx -Monitor O2 sats, breath sounds & RR-Monitor ventilator status settings-Use calming techniques in order to decreases respiratory rate and prevent hyperventilation, which could affect his ICP. -Admin sedation/pain medications (Fentanyl/Propofol) to maintain effective breathing pattern. This way client won’t fight the ventilator that is breathing for him.-Monitor ABG’s for sign of resp alkalosis of acidosis.

2. Ineffective Airway ClearanceData to Support: -Pt is intubated-Frequently had to be suctioned-Thick green/mucous-like secretions-Frequently coughs/gags on secretionsInterventions:-Suctioning prn- Monitor O2 sats, breath sounds & RR-Monitor ventilator status settings

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Problem Evaluation

Problem # Evaluation of Patient Response

1Pt lungs remained clear and suctioning helped clear secretions. The only time that his breathing pattern became a problem was when he was coming out of sedation when the porpofol was accidentally discontinued. The pt began to fight against the ventilator as was trying to breath on his own leading to hyperventilation. Calming techniques were used to get the pt to calm down and take deep breathes. We also frequently reoriented and explained to him what was going on in order to help to patient calm down and slow his respirations as well. We also restarted his propofol, which helped to sedate him and make him more comfortable. It was going to be discussed with the doctor about whether or not the pt could be taken off of the ventilator.

2The pt was continuously having thick green secretions that needed to be suctioned. However, since the pt did have head trauma and ICP was an issue, we had to really watch how many times the pt was being suctioned. The patient was able to cough on his own which is promising, but he was not yet ablt to clear his own secretions, so suctioning was still needed. Pt responded well to suctioning. RR remained normal while under sedation and lung sounds were clear.

3While I was caring for the pt his ICP levels remained between 6-9 mmHg, which is great. He did not end up needing mannitol. HOB remained elevated at least 30 degrees. Pupils were PERRL. As previously mentioned, the patient became very agitated when the propofol was discontinued. However, despite his frequent movement and hyperventilation, his ICP remained below 10 mmHg and the fluid was clear. The patient’s EVD remained in place. Once the propofol drip was restarted, the patient became more calm and relaxed and his ICP levels went back to 6-8 mmHg.

4Pt was NPO for surgery on the first day I cared for him. Normally he would receive feedings through an OG tube with Pivot 15. Since he is sedated and on a ventilator electrolytes are given special attention. 20 mEq of potassium chloride was administered and 3% NS is running IV. Pt’s I&O was closely monitored. On the first day his output was more than his input due to NPO status. Pt’s electrolyte levels remained mostly WNL.Pt is very confused due to head trauma and sedation medications that he is receiving. We frequently reoriented

N4810 Clinical Paperwork Rev 11/6/13

4.Altered Nutrition/Fluid and Electrolyte ImbalanceData to Support:Pt NPO for surgeryWeakness, OG TubeAnemic RBC 3.25, Hgb= 9.4, Hct= 38.3

5. Acute Confusion: Data to Support: -Pt sedated for last 2 weeks-Pt. only occasionally able to follow simple commands when sedated-When propofol was discontinued the pt became more alert/agitated and though his ability to follow commands increased, he was still very confused, which is why he was fighting us.Interventions:-Continually assess patient LOC and reorient -Perform an accurate mental status exam.-Check pupils-Reorient pt as necessary-Keep patient calm and relaxed-Admin Fentanyl/propofol to maintain adequate

7. Risk for injuryData to Support: -Pt has C-7 fracture. A piece of the bone broke off.-Pt also has comminuted left femur fracture.-Neck brace in place in order to keep cervical bones stable.-Order to use log rolling technique when moving pt.-Swelling in left leg-Pt not always able to move extremities when informed to do so.-Pt mostly immobile due to sedation-Pt has bilateral wrist restraints. Interventions:-Use log rolling techniques when repositioning pt.-Allow periodic rest from wrist restraints and ROM exercises.-Maintain neck brace placement to prevent complications of fracture-Assess circulation, warmth, and sensation in pt’s extremities.-Assess pt for ROM of extremities. -Turn pt q2 hrs-Using calming techniques to keep pt from overexerting with Fx’s.

6. Risk for ineffective Cerebral Tissue Perfusion:Data to Support: -Head trauma from MVA, SAH, SDH-Glasgow coma scale score of 9-EVD-Pt has been trying to move a lot since he was coming off of the sedation medication, which puts him risk for removing the EVD and hitting his head.-ICP monitoring q15minsInterventions:-Monitor ICP q15 mins-Perform neurological assessment q1hr-Check pupils for PERRLA-Avoid periods of physiologic stress-Admin mannitol, sedation meds, analgesics, and hypertonic solutions as needed to manage ICP.

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5 him and used calming/relaxation techniques when he was coming out of sedation. The problem was he came out of sedation way to fast and his porpofol wasn’t even supposed to be discontinued, so you can imagine how disorienting it would be for a patient to all of the sudden wake up in a hospital after 2 week with broken bones and a ET-tube in your mouth. So we tried to calm him as much as possible, reorient him, and restarted the propofol.

6The pt’s ICP levels remained lower than 10 mmHg. Pupils were PERRL, and physiologic was avoided by restarting propofol to maintain sedation. Hypertonic solution s, analgesics, and propofol were all used to maintain ICP lower than 10 mmHg.

7The patient remained free from further injury. Despite his C-7 fracture, the spine was not harmed, so he still has full sensation/movement of all extremities. All extremities were warm, pink, with capillary refill 3+. Pt was turned every 2 hrs and the log rolling technique was used in order to prevent further injury. Neck brace remained in place. Calming techniques were used to keep the patient from trying to move around too much in bed and propofol was restarted to sedate the patient. This kept him from pulling at all of his tubes and drips and helped relax him.

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Student Clinical Self-Appraisal

Student: Kaylee Blankenship Course N4810_____ Instructor: Sherri Brown Instructions: Please evaluate your performance during clinical today using the following concepts:

Client Advocate Professional Demeanor FlexibleCritical Thinking Communication/rapport Coordinator of CareSelf-Initiated Technical skills Team PlayerProfessional Accountability Organized EducatorLeadership Well-prepared Ability to PrioritizeNursing Process Comprehensive Assessment Knowledgeable

Areas of Strength Today (Date)

Organized: This week I really focused on honing my organization skills since this patient needed certain tasks done at specific times throughout the day. The nurse that I was with on the first day was very organized when it came to the dressing changes and charting so I was really able to use my organizational skills.

Ability to Prioritize: This was really important this week because the patient had many things that needed to be done each day as far as his care went, and one day he needed to go to surgery. We were having problems with his sedation level which needed to be addressed before dressing changes so I was able to prioritize well.

Critical thinking/self-initiated: this week I also really used my critical thinking skills. The patient was coming out of sedation since his propofol had been discontinued, but he was becoming VERY agitated and trying to get out of bed. We couldn’t figure out why his propofol had been discontinued so I started searching through his chart looking at his orders and found that the d/c of the propofol was a mistake so we re-started the drip.

Well-prepared/Knowledgeable: I made sure this week to really read through my patietn’s chart and become familiar with his history and current condition so that when I went to clinical I was well prepared and informed to help care for the patient.

Areas Needing Growth-Include plan of improvement

Leadership: I can still work on my leadership skills and my confidence level in my knowledge/skills. I feel that that will mostly come with time and experience.

Technical skills: I can still improve on my skills and becoming proficient in certain areas. This will also take time and practice.

Coordinator of care: I feel like I am still following the lead of the nurses in the hospital, which we are supposed to do, but it seems like at this point I should be taking more of a lead in the patient’s care. I will get more of this type of experience during my preceptorship.

Instructor Comments:

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Student’s Name: Kaylee Blankenship Pt’s Initials: J.R. Date: 4/16/15

Atrial rhythm: Regular or Irregular Ventricular rhythm: Regular or Irregular

Atrial Rate: 114 bpm Ventricular rate: 114 bpm

PR interval: Hard to determine from print out QRS interval: Hard to determine from print out

QT interval: Hard to determine from print out

Is AV conduction normal? (Y/N)______________ If not, why is it abnormal?

P wave normal? (Y/N) Regular QRS complex normal? (Y/N) Regular, maybe a Little shorter than normal becuase he is in ventricular tachycardia.

Are all of the QRS complexes the same? (Y/N) ___________________

Are there premature beats? (Y/N) __________ , Atrial or ventricular

Interpretation of rhythm: Ventricular tachycardia

Potential hemodynamic consequences of this rhythm and interventions for this rhythm:

The patient was coming out of sedation at this time since his propofol drip was discontinued. As he was becoming less and less sedated, he started to fight the ventilator, pull on his restraints, and try to get out of bed. Since he has had brain trauma, coming out of sedation so fast can be scary especially if you have been out for about two weeks. His body was having a fight or flight response, which lead to an increased heart rate (ventricular tachycardia). We responded to this by restarting his propofol drip, which calmed him, and his heart rate dropped back between 60-100 bpm.

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Student Name: Kaylee Blankenship Date: 4/24/15 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: 20 points possible _____

a. Health historyb. All blanks and/or issues are addressed

2. Each medication includes: 20 points possible _____a. Nameb. Rationalec. Side effectsd. Nursing implications-specific to this patient

3. Lab Diagnostics 10 points possible _____a. Testb. Resultsc. Implications & Teaching

4. Problem Identification includes 20 points possible _____a. Correctly lists individualized needsb. Correctly identifies problemsc. Problems are prioritized and numbered, each problem in priority of importance d. Map includes at least five physiological problems, discharge planning and patient educatione. Each problem includes:

i. Nursing diagnosisii. Data to supportiii. Medicationiv. Nursing treatment (interventions)

5. Planned interventions includes 10 points possible _____a. Interventions appropriateb. Correctly prioritizes interventionsc. Assessments performedd. Communicatione. Patient teachingf. Discharge planning

6. Evaluation of Interventions includes 10 points possible _____a. Evaluates physical interventionsb. Evaluates teaching

7. a. Priority Assessments are appropriate to diagnoses 10 points possible ____b. Clinical Paperwork is complete

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Total Points _____________/100 = ____%

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