CSU, STANISLAUS B.S.N.

CLINICAL PLAN OF CARE

Patient Data
Student __Tuyet Nguyen___________

Date of Care __9/18-9/19______ Room Number _3739A_______ Code Status: __Full____

Pt. Initials _J.A._ Gender_M__ Age_82__ Height_510__ Weight__79.5kg (9/17)__ BMI _25.1__ Spirituality_Christian__Ethnicity _Caucasian
Admitting Diagnosis: __Acute coronary syndrome (ACS); Pericarditis; Pericardial effusion ______________________________________
Vital Signs: Temp _36.7C_ HR _82_ RR _16_ B/P _127/64_ O2 Sat _95%_ Pain Scale & Scale Type_2-3/10 (numeric pain scale)
He
appeared so depressed that he seemed like he would not care if he was really in pain. When I asked if he was in pain and rated the pain, he
answered, I guess..., I dont know...may be 2-3, I dont know. He has hx of depression__________
History related to this admission__82 years old male with Hx of depression and DVT presented with generalized weakness for 2 days (not able
to walk, diarrhea on 9/8, low grade fever 100F, an episode of near syncope 9/9 felt light headed & about to pass out. Called EMS after near
syncope episode. EMS found him diaphoretic w/ EKG showed ST elevation, EMS gave him aspirin 325 mg & morphine 2 mg en route. EKG
reviewed by cardiologist in ED & felt it could be pericarditis; Troponin is (-) rule out acute MI. Denied chest pain, SOB, palpitation____________
Past Medical History _DVT (Left leg filter placed in 2010), Colon cancer, stomach cancer, colonic polyps, essential HTN (benign), Chronic
Anemia, Chronic Kidney Disease; chronic joint pain_______________
Admit Date __9/9/14_____ POD __2 (pericardial/subxyphoid pericardiostomy on 9/15)___
Surgical History & Date__Colonscopy (6/2010); Appendectomy; Esophagogastroduodenoscopy (EGD) 6/2014; Cataract removal;
Cholecystectomy; Pacemarker; Thyroidectomy_______________________ MD(s) __Unknown___________________

Diet _Regular__ Activity _Ambulate w/ walker & assistance

Foley _____N/A______ Feeding Tube & Rate _____N/A_________
Advance Directive:
Yes ________ No ___x____
Drains/ Tubes __Chest tube removed 9/17 @1725__________________
Isolation __N/A_____ VS Freq ___q4h__________
Glucose Monitoring _N/A_ DVT Prophylaxis_Heparin 5000 units SubQ Q12H_
Vascular Access:
PCA/Epidural __N/A___
Telemetry & Rhythm _9/9 diffuse/widespread ST elevations indicated pericarditis (Note: localized ST elevation
acute MI) (attached strip below)
__9/18 Basic normal sinus rhythm with occasional PVCs_(attached strip below)___________
IV Site: _9/17 Lt forearm_ IV Solution & Rate: _NS 25mL/hr___ Safety Considerations _Confusion, Fall, Cardiac______ Restraints __N/A___
IV Site: ___________ IV Solution & Rate: _________________ Labs for day of clinical __ CMP______________________________
Dressing Changes & Frequency:_q1-2 days (dressing changes
for chest tube removal and pericardiostomy site)____________ Scheduled Procedures __CXR__________________________________
_____________________________________________
Procedures done this admission _EKG____________________________
Oxygen __Room air_____________________
Respiratory Treatment: _N/A______________________
Vent Settings: ______N/A_____________________________________
Advanced Hemodynamic Monitoring & Values ____N/A______________
IV Drips Medications Dosage & Rate: ___N/A_____________________
Notes on Pathophysiology:
The cause of acute pericarditis most often is idiopathic (unknown). An inflammatory response is the characteristic pathologic finding in acute
pericarditis (autoimmune). Pericardial effusion is the presence of an abnormal amount of fluid and/or an abnormal character to fluid in the
pericardial space. Pericardial effusion is complication of pericarditis. http://emedicine.medscape.com/article/157325

treatment#aw2aab6b6b2


This explains why a combination of Aspirin, Colchicine, Vancomycin, and Ceftriaxone are prescribed
Medication
Generic & Trade Name
Dose, Route, Frequency

Mechanism of Action
Classification

Patient-Specific Rationale

Allergies: NKDA
For fever > 38C. Pt had a low grade
fever right before admission.
Pericarditis may trigger fever. Also
help with mild pain (1-3)

Acetaminophen (Tylenol)
650 mg PO Q4H PRN

Inhibits the synthesis of

prostaglandins that may serve
as mediators of pain and fever

Ascorbic Acid (vitamin C)

500 mg PO daily

Fortifies immune system thus

improving wound healing;
Necessary for collagen
formation and tissue repair;
resistance to infection

Vitamin supplement is beneficial

for 82 years old pt with wounds
from chest tube and
pericardiostomy window

infection risk, tissue repair for his
wounds

Vancomycin
750 mg in D5W 150 mL
IVPB Q18H

Anti-infective: Binds to
bacterial cell wall, resulting
in cell death.

A combination of Vancomycin and

Ceftriaxone is often used to treat
pericarditis. Board spectrum
antibiotics to cover the infection
while waiting for culture result
(No Vancomycin trough level noted
since admission)

Aspirin EC (ECOTRIN)
80 mg PO daily with
breakfast

Produce analgesia and reduce

inflammation & fever by
inhibiting production of
prostaglandins. Decreases
platelet aggregation.

Aspirin controls inflammation thus

reduces pain d/t pericarditis.

Atorvastatin (Lipitor)
80 mg tab PO daily

Lipid-lowering agents:
Inhibits HMG-CoA
reductase an for catalyzing
synthesis of cholesterol.

Pt has mild plague in carotid artery

indicating atherosclerosis
Lipitor
prevents further damage.

Nursing Considerations
(Assessment implications, side effects, reasons to hold
med, administration rate, etc)
- No significant s/e if used as prescribed
- Max 4g/day to avoid hepatotoxicity
- Avoid alcohol; Reassess temperature
- Monitor liver function (AST, ALT, bilirubin)
- Acetylcysteine (Mucomyst) is the antidote.
- No significant s/e
- Assess s/sx vitamin C deficiency (faulty bone and
tooth development, gingivitis, bleeding gums, loosened
teeth)
- Teach pt excess doses may lead to diarrhea and urinary
stone formation; foods high in ascorbic acid (citrus
fruits avoid grapefruit d/t Lipitor, tomatoes,
strawberries, cantaloupe, and raw peppers)
- Monitor nephrotoxicity (I&O, daily wt, cloudy/pink
urine may be sign of renal toxicity); Phlebitis; "red man"
syndrome (with rapid infusion); Superinfection
- S/sx of anaphylaxis (rash, pruritus, laryngeal edema,
wheezing)
d/c & notify Dr stat, epinephrine,
antihistamine, resuscitation equipment
- Vancomycin trough should be 10-20 mcg/mL
- S/e: dyspepsia, epigastric distress, nausea
- Adverse effect: Geri ( risk of adverse reactions
especially GI bleeding; more sensitive to toxic level),
anaphylaxis and laryngeal edema
- Pt at increased risk of bleeding d/t using heparin for
DVT prophylactic concurrently. Assess s/sx of bleeding
(black/tarry stool, bleeding gum, bruises, etc...)
- S/e: abdominal cramps, constipation, diarrhea, flatus,
heartburn
- Adverse effects: rhabdomyolysis (release of
myoglobin in blood stream d/t muscle fiber breakdown
which is harmful to kidney); liver damage
- Monitor liver function, s/sx of liver damage ( jaundice,
hyperbilirubinemia)
d/c if present
- May cause alkaline phosphatase and bilirubin.
- Monitor muscle tenderness and if CPK > 10 times than

upper normal limit (10 - 120 mcg/L)
myopathy
d/c

- Avoid grape fruit or grape juice
Bupropion (Wellbutrin)
100 mg PO daily

Antidepressant - neuronal
reuptake of dopamine,
serotonin, norepinephrine in
CNS.

Ceftriaxone (Rocephin)
1000 mg in 0.9% NaCl 50
mL IVPB Q12h

Anti-infectives - Binds to the

bacterial cell wall membrane,
causing cell death.

Colchicine (Colcrys)
0.6 mg tab PO TID

Anti-inflammatory agents Interferes with the functions

of WBCs in initiating and
perpetuating inflammatory
response inflammation

Docusate Sodium (Colace)

100 mg tab PO TID

stool softeners - Promotes

absorption of water into stool,
resulting in softer fecal mass

Heparin injection
5000 units subQ Q12H

Anticoagulants - preventing
the conversion of fibrinogen
to fibrin to prevent thrombus
formation

Pt has Hx of depression. He
appeared depressed during the day
of my care. He remained very quiet
and passive. He didnt want to eat
and ate very little when encouraged.
A combination of Vancomycin and
Ceftriaxone is often used to treat
pericarditis. Board spectrum
antibiotics to cover the infection
while waiting for culture result

- Common s/e: dry mouth, N/V, tremor, agitation,

headache
- Adverse effects: seizures, suicidal thought
- Asses mental status & mood change

- S/e: phlebitis
- Adverse effects: seizures, pseudomembranous
(diarrhea, abdominal cramping, fever, and bloody stools
colitis), anaphylaxis (rash, pruritus, laryngeal edema,
wheezing)
d/c and notify Dr stat.
- May cause AST, ALT, alkaline phosphatase,
bilirubin, LDH, BUN, and creatinine
- Do not infuse in same IV lumen as Ca-containing
solution
Anti-inflammatory effect of
- S/e diarrhea, nausea, vomiting
Colchicine helps reduce
- Adverse effect: agranulocytosis, aplastic anemia
inflammation d/t pericarditis
- Avoid grapefruit juice which may levels and risk of
(autoimmune) and thus reduces pain toxicity ( muscle pain or weakness, tingling or
numbness in fingers or toes; pale or gray color to lips,
tongue, or palms of hands; severe diarrhea or vomiting;
unusual bleeding, bruising, sore throat, fatigue, malaise,
or weakness or tiredness)
- May cause platelet count, leukopenia, aplastic
anemia, and agranulocytosis; in AST and alkaline
phosphatase
Treat constipation; Pts last BM
- No significant s/e except mild cramp
was on 9/15. Abdomen was
- Assess for abdominal distention, presence of bowel
distended upon palpated;
sounds, and usual pattern of bowel function.
Protocol to prevent constipation to
Assess color, consistency, and amount of stool.
- fluid, mobility, fiber if not contraindicated
minimize straining and prevent
vagal response
DVT Prophylaxis; Pt has Hx of
- S/e & adverse effects: bleeding, heparin-induced
DVT on left leg
thrombocytopenia, anemia
- Assess for signs of bleeding (bleeding gums;
nosebleed; unusual bruising; black, tarry stools;
hematuria; fall in hematocrit or BP; guaiac-positive
stools)
notify
- Monitor aPTT should be 1.5 to 2.5 times the normal
value (21-35 sec), platelet count
pts platelet count
was 309 when given.

- May cause AST and ALT levels.

- Protamine sulfate is the antidote
Lorazepam (Ativan)
0.5 mg PO BID PRN

Anti-anxiety: potentiating
GABA to decrease anxiety

Given if pt experiences anxiety,

insomnia.

Magnesium sulfate
2g in sterile water 50 mL
IVPB PRN (For Mg level
1.5 1.9)

Magnesium replacement

Use as replacement therapy for low

Mg levels to prevent adverse effects
i.e. cardiac arrhythmia, muscle
weakness

Magnesium Hydroxide
(Milk of magnesium/
MOM) 30 mL PO daily

Mineral and electrolyte

replacements/supplements;
Laxative

Metoprolol Tartrate
(Lopressor)
12.5 mg PO BID

Beta-blocker: Blocks
stimulation of beta1adrenergic receptors to HR
and BP

Treat constipation; Pts last BM

was on 9/15. Abdomen was
distended upon palpated;
Prevent constipation also prevent
straining (vagal response) which
can cause dysrhythmias
oxygen demand of the heart by
HR, BP, and contractility. Pt had
pericardial effusion which
compressed the heart
reduce
workload of the heart using
Metoprolol

Olanzapine (Zyprexa)
5 mg PO bedtime

Antipsychotics/mood
stablilizers: Antagonizes
dopamine and serotonin type
2 in the CNS

Pt has Hx of depression. He
appeared depressed during the day
of my care. He remained very quiet
and passive. He didnt want to eat
and ate very little when encouraged

- S/e: dizziness, drowsiness, lethargy
risk for fall,

ambulating require assistance
- Adverse effects: physical/ psychological dependence,
tolerance, seizure
- Assess degree of anxiety and mental status
- Avoid alcohol or other CNS depressant drugs
- Flumazenil (Romazicon) is the antidote
- Infuse over 60 minutes
- Side effects: drowsiness, decreased respiratory rate,
arrhythmias, bradycardia, hypotension, diarrhea, muscle
weakness, flushing, sweating, hypothermia
- Monitor pulse, blood pressure, respirations, and ECG.
Respiration should be at least 16 before each dose.
- Monitor neurologic status, seizure precautions. Patellar
reflex should be tested before each IV dose. If absent,
no additional doses should be administered until
positive response is obtained.
- Monitor I/O. Urine output should be maintained at a
level of at least 100 mL/ 4 hr.
- S/e: diarrhea
- Monitor Mg level
last Mg level WNL 1.8
- Assess for abdominal distention, presence of bowel
sounds, and usual pattern of bowel function.
Assess color, consistency, and amount of stool
- S/e: fatigue, weakness, erectile dysfunction
- Adverse effects: bradycardia, HF, Pulmonary edema
- Monitor BP, ECG, and pulse frequently
- Hold if apical pulse < 50 bpm & arrhythmia; If HR
<40 bpm & CO
atropine 0.250.5 mg IV
- Monitor s/sx HF (I&O, daily wt, dyspnea,
rales/crackles, weight gain, peripheral edema, JVD)
- May cause serum alkaline phosphatase, LDH, AST,
and ALT levels.
- S/e: agitation, delirium, dizziness, headache,
restlessness, sedation, weakness, constipation, dry
mouth, liver enzymes, tremor
- Adverse effects: neuroleptic malignant syndrome
(fever, respiratory distress, tachycardia, seizures,
diaphoresis, hypertension or hypotension, pallor,
tiredness, severe muscle stiffness, loss of bladder

control); seizures; suicidal thought; agranylocytosis;

akathisia; tardive dyskinesia
- Assess mental status
Ondansetron (Zofran)
4 mg/2 mL IV Q6H PRN

Pantoprazole (Protonix)
40 mg PO BID 30 min
before breakfast & diner

Antiemetics: Blocks the

effects of serotonin at 5-HT3
receptor sites located in vagal
nerve terminals and the
chemoreceptor trigger zone in
the CNS.
Antiulcer agents - acid
secretion

Potassium Chloride
10 mEq in 100 mL IVPB
PRN

Mineral and electrolyte

replacements/supplements:
Maintain acid-base balance,
essential to transmission of
nerve impulses; contraction
of cardiac, skeletal, and
smooth muscle

Psyllium (Metamucil)
Powder 1 packet PO daily

Bulk-forming laxatives:
Combines with water in the
intestinal contents to form an
emollient gel or viscous
solution that promotes
peristalsis
Mineral and electrolyte
replacements/supplements:
Serves as a cofactor for many
enzymatic reactions.

Zinc Sulfate
220 mg PO TID

Pt complained of nausea and

vomiting and did not want to eat on
9/17 night but felt less nauseated
during my care and ate a little when
encouraged.
Prophylactic - prevent gastric ulcer,
nausea, vomiting which may lead to
other complications (aspiration,
pneumonia, dysrhythmias...)
Prevention of K depletion;
hypokalemia can cause
dysrhythmias (flattened or inverted
T waves, ST depression and a wide
PR interval).
- K>3.5
Do not give
- K (3.1-3.4)
give over 1 hr for 2
doses
- K <3.0
give over 1 hr for 4
doses
Treat constipation; Pts last BM
was on 9/15. Abdomen was
distended upon palpated;
Prevent constipation also prevent
straining (vagal response) which
can cause dysrhythmias
Zinc supplement increases wound
healing, senses of taste and smell.
Pt had pericardiostomy on 9/15, did
not want to eat & ate very little
when encouraged

- S/e: headache, dizziness, constipation, diarrhea

- Adverse effect: torsade de pointes, QT prolong
- Monitor ECG in patients with hypokalemia,
hypomagnesemia, HF, bradyarrhythmias, or patients
taking concomitant medications that prolong the QT
interval.
- No significant s/e
- Adverse effect: pseudomembranous colitis
(abdominal cramping, fever, and bloody stools)
- Adverse reactions/Side effects: confusion,
restlessness, weakness, dysrhythmias, ECG changes
- Monitor pulse, BP, and ECG
- Toxicity (slow, irregular heartbeat; fatigue; muscle
weakness; paresthesia; confusion; dyspnea; peaked T
waves; depressed ST segments; prolonged QT
segments; widened QRS complexes; loss of P waves;
and cardiac arrhythmias)
give sodium bicarbonate to
correct acidosis, dextrose and insulin to facilitate
passage of potassium into cells, calcium salts to reverse
ECG effects
- Adverse effects/S/e: cramps, intestinal or esophageal
obstruction, nausea, vomiting
- Instruct pt avoid straining during bowel movements
(Valsalva maneuver).
- Dont use laxatives when abdominal pain, nausea,
vomiting, or fever is present.
- S/e: gastric irritation, nausea, vomiting
- Instruct patients to notify health care professional if
severe nausea or vomiting, abdominal pain, or tarry
stools occur. .

LABORATORY DATA

LABS

Normal Range

RESULT 1

RESULT 2

(Fill in Hospital Norms)

9/16/14

9/17/14

RESUL
T3

Reason for abnormal lab values r/t diagnosis &

nursing implications

9/18/14

CBC
WBC
RBC
Hemoglobin
Hematocrit
MCV
MCH
MCHC
RDW
PLT COUNT
WBC DIFF
NEUTROPHIL %
BANDS %
LYMPHOCYTE%

4.0-11.0
4.40-6.00
13.5-18.0
40-52
80-100
27.0-33.0
31.0-36.0
< 16.4%
150-400

9.3
4.00 L
12.6 L
36.3 L
91
31.5
34.7
14.5
310

9.4
4.12 L
12.9 L
37.2 L
90
31.3
34.7
14.5
309

WNL
Low values indicate anemia. Pt has Hx of
chronic anemia. Also pt has appetite and did
not eat well.
WNL
WNL
WNL
WNL
WNL

49-74%

72

70

WNL

26-46%

13 L

17 L

MONOCYTE %
CHEMISTRY
Sodium
Potassium

2.0-12.0

12

11

A lymphocyte % may be due to

chemotherapy or radiation therapy or
exposure. Pt has Hx of colon cancer &
stomach cancer and lymphocyte % might be
related to previous cancer treatments
WNL

136-145
3.5-5.1

140
4.1

140
3.7

139
4.0

Chloride
CO2(bicarb)venous
Glucose
Calcium

98-107
21-32
70-99
8.2-10.2

109
23
98
8.8

107
22
89
8.9

107
22
85
8.9

WNL
WNL Pt has PRN potassium chloride
replacement on sliding scale. No KCl given if
K >3.5
WNL
WNL
WNL
WNL: Ca can cause dysrhythmias and poor
bleeding. Continue to monitor since pt has
increased risk of bleeding d/t Heparin and
Aspirin usages.

Comment [sb1]: This is normal for

the most part

Comment [sb2]: It is ok level doesnt

usually stay low for long term but is
usually nondiagnostic

phosphorus
Magnesium

1.8-2.4

1.7 L

1.9

1.8

BUN
Creatnine
GFR
LIPID PANEL
HDL

6-25
0.6-1.10
>60

17
1.16 H
58 L

16
1.16 H
58 L

>40

19
1.22 H
55 L
9/10/14
34 L

LDL
Cholesterol
Triglycerides
LIVER PANEL
Total protein
Albumin

0-100
0-200
0-150

75
122
67

6.4-8.2
3.2-4.7

6.5
2.5 L

6.5
2.6 L

Bilirubin Total
Alk phosphatase
AST
ALT

0-1.1
26-137
0-37
0-60

0.5
96
92 H
66 H

0.6
100
68 H
66 H

0-3

9/10/14: 224 H

Lipase
Amylase
Ammonia
Lactate
Serum Ketones
CARDIAC PANEL
CPK
CPK-MB
C Reactive Protein
Inflammatory

Pt is on Mg Sulfate 2g PRN to keep it WNL.

Continue to monitor Mg level
WNL
Pt has Hx of chronic kidney disease

Low HDL increases the risk of cardiovascular

diseases (atherosclerosis)
WNL effective Lipitor treatment & also pt
did not eat well.

WNL low end may d/t lack of appetite

Low values indicated malnutrition.
Hypoalbuminemia may cause
generalized edema. Pt did have generalized
trace (+1) edema (Note Ca may be
associated with hypoalbuminemia)
WNL
WNL
Elevated values might indicate liver
dysfunction. Recent surgery might cause
elevated value. However, medications like
Lipitor, Ceftriaxone, Heparin, Metoprolol can
all cause elevated AST, ALT levels.

Protein produced by liver; Marker of

inflammation that can predict risk of cardiac

Comment [sb3]: This is a normal

finding that is normal for this patient
and the age of this patient

Troponin I
Myoglobin
BNP
COAGULATTION
PT
INR ratio

PTT
Fibrin level
Bleeding time
D-Dimer
UA collection type
Urine color
Urine appearance
Specific gravity
Urine pH
Urine glucose
Urine bilirubin
Urine blood
Urine Ketones
Urine Nitrites
Urine Protein
Urine Leukocytes

0.00-0.05

9/10/14: <0.02

12.1-15.3 sec
0.9-1.1

15.4 H
1.2 H

Yellow
Clear
1.003-1.035
5.0-8.0
Neg
Neg
Neg
Neg
Neg
Neg
Neg

Unknown (9/9/14)
Yellow
Clear
1.016
6
Neg
Neg
Neg
Neg
Neg
Neg
Neg

disease and cardiac events

CRP indicated pericarditis d/t
autoimmune triggering inflammation
Rule out acute MI

15.3
1.1

13.8
1.1

Measures the clotting ability of the blood.

PT & INR are secondary to Heparin for DVT
prophylaxis. He had hx of DVT on left leg.
Continue to monitor lab values and watch for
s/sx of bleeding.

WNL

Comment [sb4]: When patient is on

heparin the normal thing to measure is the
PTT the PT and INR are usually
measured if the patient is on coumadin

DIAGNOSTIC DATA

9/9/14: Normal Sinus Rhythm; Low voltage QRS; diffuse ST elevation
Pericarditis
9/12: Sinus rhythm with occasional premature ventricular complexes; Low voltage QRS; Prolonged QT
Transthoracic 2D
9/10/14: Mild tricuspid regurgitation; Pericardial thickening with density lesion between the visceral &
Echocardiogram &
parietal pericardium can be seen near the base midportion of the right ventricle. Both the visceral &
Droppler
parietal pericardium appeared to be thickened; EF:50-55%
XR chest 1 view AP or PA 9/15/14: Cardiac (mild cardiomegaly); Left side pulmonary congestion
9/16/14: Minimal streaky opacification is noted at the lung bases suggestive of subsegmental atelectasis
XR chest 2 view PA
9/18/14: The lungs are well expanded & clear apart from mild chronic interstitial lung changes & a few
lateral
thin foci of subsegmental atelectasis and/or interstitial lung scarring. A left sided chest tube has been
removed yielding no evidence residual (100cc drained out). Diaphragmatic angles are blunted
posteriorly by lateral view as may be consequence of small volume of pleural effusion & rated basilar
atelectasis.
NIVL Duplex scan
9/13/14 Mild degree of plaguing was seen in left common carotid artery, at the carotid bulb and its
extracranial bilateral
bifurcation vessels origin. No significant stenosis.
complete
Pericardial
9/15/14: Pericardium excision (severe acute and chronic pericarditis with reactive changes)
window/subxyphoid

Section of pericardium shows severe mixed acute and chronic inflammation of recent and old
pericardiostomy
hemorrhage. Also noted are prominent congestion, edema, & reactive changes of mesothelial cells &
stromal cells. Negative for carcinoma and lymphoma
Sputum culture
9/15/14: No acid fast bacilli seen
Pleural fluid culture
9/15/14: No yeast/fungal seen, No organism seen
ECG

Dx 1: your interventions should stick to your dx example: bowel care and Ativan are another dx: ask yourself will Colace help cardiac
output? Will MOM help cardiac output? Also an EF of 50-55% is normal so you have a risk for decrease cardiac output not an actual dx.
But great job!!!!!
DX 2: data to support: You give lots of xray results. Make sure you give assessment findings what was the breathing pattern like?
Kussmals at what rate???? Dont just give XR findings.
DX 3 good job

1. Decreased cardiac output r/t pericardial effusion

Data to Support: EF 50-55%; Transthoracic 2D
Echocardiogram & Droppler showed pericaridial effusion;
Chest tube placement 100cc; Metoprolol to reduce
workload on the compressed heart; Generalized edema (+1);
Arrhythmias (ST elevation on 9/9 & occasional PVCs on
9/18); Mild cardiomegaly which compromises CO
Interventions: - Monitor VS especially lung sounds, heart
sounds, O2 sat, give oxygen if s/sx of hypoxia;
- Monitor cardiac rhythm; - Monitor chest tube drainage;
I&O; - Place pt in semi-Fowlers or high Fowler to WOB &
preload to heart workload; - Provide cluster care; Monitor bowel function/ bowel protocol to minimize
straining (vagal stimulation): Colace, Metamucil, MOM
(PRN); - Assess for anxiety which can HR and administer
Ativan as prescribed; - Check BP, pulse before administering
Metoprolol as prescribed.
10. R/F skin breakdown
Data to Support: Generalized edema, fragile skin, bruises
on left arm, face, left chest; He had a brief on and most
often urinated in there; He had a small redness area
(approximately 2cmx1cm) faded away when putting
pressure on over coccyx area.
Interventions: - Reposition pt q2h and encourage him
reposition himself as frequent as possible;
- Support pillows under one side to pressure on buttock
area; - Notify the nurse; - Change his brief as soon as it is
wet and put skin barrier on; - Remind pt to use call light
when he wets the brief and response to call light in timely
manner

9. Risk for vascular trauma r/t Vancomycin and

Ceftriaxone infusions
Data to Support: pt having IV Vancomycin & Ceftriaxone
Interventions: -Monitor patency and flow rate at regular
intervals; - Flush vascular access per MMC policy; Monitor IV site for burning, pain, erythema, temperature,
infiltration, extravasation, edema, secretion, tenderness, or
induration
Remove promptly if present

2. Ineffective breathing pattern r/t pericardial

effusion & small pleural effusion
Data to Support: - Diaphragmatic angles are
blunted posteriorly by lateral view as may be
consequence of small volume of pleural effusion &
rated basilar atelectasis; - Left side pulmonary
congestion; - Subsegmental atelectasis; Diminished
lung sounds at the base; Incentive spirometry max
at 750
Interventions: - Encourage slow, deep breath,
turning, coughing; Emphasize importance of
incentive spirometry & encourage pt to use it q1-2h
while awake; - Elevate HOB at least 30-45 degree;
- Monitor respiratory effort (rate, depth, WOB); Monitor VS, especially lung sounds and O2 sat
Chief Medical Diagnosis: Acute coronary
syndrome (ACS); Pericarditis; Pericardial
effusion
Priority Assessments: ABC, VS, pain, lung
sounds, heart sounds, s/sx of bleeding, PT, INR,
s/sx of infection from 2 wounds (chest tube
removal and pericardiostomy window), pedal
pulses, pain on legs (pt had hx of DVT),
telemetry

7. R/F cardiac tamponade r/t pericardial effusion

Data to Support: EF 50-55%; Transthoracic 2D
Echocardiogram & Droppler showed pericaridial
effusion; Section of pericardium showed severe
mixed acute and chronic inflammation of recent and
old hemorrhage. Also noted are prominent
congestion, edema, & reactive changes of
mesothelial cells & stromal cells; - Chest tube
placement to drain fluid (100cc); +1 edema.
Interventions: Monitor VS, chest pain, confusion,
anxious, restlessness, dyspnea, tachypnea,
tachycardia, JVD, pulsus pardoxus ( SBP with
inspiration).

8. R/F injury/bleeding r/t Heparin + Aspirin use

Data to support: A bruise on his left eye d/t falling at home; A bruise (4cmx1.5cm) on his left forearm d/t
accidentally hitting somewhere; minor bruises around pericardiostomy window & chest tube removal sites; - Unsteady
gait w/ walker; - Heparin + Aspirin.
Intervention:- Monitor PT, INR, aPTT, platelet; - S/sx of bleeding (tachycardia, black/tarry stools, confusion,
LOC...); - Activate bed alarm; - Encourage pt to use call light when need help to prevent fall; Response call light
quickly; - Cluster free room; - If tolerated, ambulate slowly with walker and gait belt support; - Educate pt to be extra
careful and avoid hitting around or fall d/t Heparin and Aspirin use.

3. Acute Pain r/t pericardial inflammation,

pericardiostomy window surgery, chest tube placement
Data to Support: Grimacing when moving and when
checking the dressings over chest tube removal site and
pericardiostomy window site; Rated 2-3/10 (Note: I
think depression was affecting his subjective pain
rating. At first he told me no pain, I said I saw him
grimacing, then he said it could be 2-3/10.
Interventions: Use OLDCART to assess the pain;
Administer Acetaminophen as prescribed for rated mild
pain (1-3); Reassess pain after
4. Infection/Inflammation r/t pericarditis (Pt was started on
Vanco & Ceftriaxone right after Dx of pericarditis; Sputum &
pleural fluid for culture 5 days after pt on antibiotics and have
not seen any organism growth. I am not sure if antibiotics
already killed all bacteria or just d/t autoimmune or infection
triggered autoimmune)
Data to Support: Section of pericardium shows severe mixed
acute and chronic inflammation of recent and old hemorrhage;
C Reactive Protein of 224; Anticipate combination of antiinfective agents (Vancomycin, Ceftriaxone) and antiinflammatory agents (Colchicine, & Aspirin) to treat
pericarditis
Interventions: Monitor VS, temp, WBC; Check culture result;
Administer Vancomycin, Ceftriaxone, Colchicine, & Aspirin as
prescribed; Get Vancomycin trough level if ordered
5. Depression
Data to support: Pt had hx of depression; Remained very
quiet and passive during my care; Didnt want to eat; if
really encouraged, pt only ate few bites; Wellbutrin &
Zyprexa
Intervention: - Encourage pt to express his feeling; - Initiate
conversation; - Ask for his favorite foods or drinks and
request a special order for him; - Ask and encourage him to
watch his favorite TV shows; Administer Wellbutrin &
Zyprexa as prescribed; Asses mental status or any sudden
change in mood
6. Constipation r/t decreased activity & s/e of
medications
Data to Support: LBM 9/15, decreased bowel sounds,
abnormal distension, Colace, MOM, Metamucil
Interventions: Increase fluid if not contraindicated;
activity with assistance of walker and stand-by
assistance but make sure maintain activity level that
does not compromise CO (Pts at high risk of bleeding,
so extra careful when helping ambulate pt to avoid fall);
Administer Colace, MOM, Metamucil as ordered

Problem Evaluation
Problem
#
1

Evaluation of Patient Response

- VS were stable during my shift (@1100: 36.7C, HR 82, RR 16, B/P 127/64, O2 Sat 95%, Pain 2/10)
- Normal heart sounds except really faint murmur heard best at the left lower sternal border probably d/t
mild tricuspid regurgitation evidenced on echocardiogram.
- Lung sounds were clear but diminished at the base
- Rhythm strip on 9/18: Basic sinus rhythm with occasional PVCs (For basic sinus rhythm: Ventricular
heart rate 83; 1 p wave before each QRS, normal PR intervals, normal QRS)
- Left-sided chest tube were removed on 9/18 morning by the Dr. yielding no residual confirmed by CXR
- I&O (upto 1300 on 9/18): I ( 550mL including NS 25mL/hr & Vancomycin in 150 mL bag &
Ceftriaxone in 50 mL bag & water for meds & Metamucil powder packet); O ( 250-300 mL of urine +
loose stools after administering Colace, MOM, Metamucil)
Decreased urine output might be d/t Hx of
chronic kidney disease
- HOB elevated at 30-45 degree; Cluster care provided
- Pt was A&O x 4 with no signs of restlessness, agitation, or confusion. No cyanosis present;
Generalized (+1) edema noted.
- Administered Metoprolol (Apical pulse 82, BP 127/64), Colace, Metamucil, MOM as prescribed. Pt
tolerated well.
- Pt used incentive spirometer twice, 2 hr apart, when encouraged. Max still at 750; Deep breaths,
coughing and turning after using incentive spirometer; Pt acknowledged the importance of deep
breaths, turning, and coughing and agreed to do more often
- HOB elevated 30-40 degree; Unlabored respiratory effort unless after short ambulating; Lung sounds
clear but diminished at the base; O2 sat 95-96%
- Pt had a rated mild pain around chest tube removal and pericardiostomy window sites, dull pain when
moving or coughing, felt better if stay still.
- Administered Acetaminophen. Pt tolerated well w/o complications
- Reassessed pain after 1h, pt stated 0/10
- Stable VS; No fever; No elevated WBC; No organism growth seen on sputum and pleural fluid cultures
(9/18)
- Administered Vancomycin, Ceftriaxone, Colchicine, & Aspirin as ordered. Pt tolerated well w/o
complications
- Spent time with pt when he was awake; Gave him bed bath, change his grown, change his briefs as
soon as wet; As the day went on, pts mood was better and some smiles noted; He appreciated my help
and spending time with him.
- Pt ate more during lunch and agreed to have a short ambulating. In the morning, he did not want to eat
or get up on a chair.
- Administered Wellbutrin & Zyprexa and no sudden mood change noted. In general, he still remained
quiet throughout the day.

- Pt is not on fluid restriction; Encouraged him to drink more water; Pt had a short slow ambulating after
lunch w/o complication; Administered Colace, MOM, Metamucil as prescribed. Pt had BM about 45
after (large amount of loose brown stool).
- Stable VS; No chest pain; Pt was A&O x 4 with no signs of restlessness, agitation, dyspnea, or
confusion. No cyanosis present; No JVD, No pulsus pardoxus.
7
- PT 13.8; INR 1.1; Platelet 309; Other than a bruise on his left eye d/t falling at home, a bruise on his
left forearm d/t accidentally hitting somewhere, and minor bruises around pericardiostomy window &
8
chest tube removal sites, there was no s/sx of internal bleeding
- Bed alarm activated; Pt used call light when need help; Promptly responded to call light; Cluster free
room; Slow ambulating with walker, gait belt, and stand-by assistance.
- IV site on left forearm flushing per MMC protocol with no resistance. No signs of burning, pain,
9
erythema, temperature change, infiltration, extravasation, edema, secretion, tenderness, or induration at
IV site.
- Repositioned pt q2h and encouraged him reposition himself;
10
- 2 pillows supported under one side (changing side when repositioned) to pressure on buttock area
- Notified the nurse about the redness over buttock area
- Changed his brief as soon as it was wet and applied skin barrier on after changing
- Pt used call light when need help; Promptly responded to call light
Very very nice job!!!!!!!!!
6

Student Clinical Self-Appraisal

EXAMPLE
Weekly (turn in with Care Plan/Map)
Student _Tuyet Nguyen__ 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
Communication/rapport
Technical skills
Organized
Well-prepared
Comprehensive Assessment

Areas of Strength Today (Date):9/18/14

Self-Initiated/Leadership:
While my patient was sleeping, I offered my
availability with CNAs so they can call me any time
for help. I followed and helped CNAs with their
patients. I also helped the nurse with her other
patients. I asked questions when I did not
understand or wanted to get info for the care plan.
The only time I sat down was for updating labs or
pts new info. Time will fly fast when busy.
My patient was discharged to a nursing home at
3pm on 9/18, so I quickly pick another patient.
Ability to Prioritize
Communication/rapport:
I stayed with my patient and talked quite often
during my shift because I wanted to encourage him
to eat more. I went in to check on him q45-1hr and
changed his brief if wet. I gave him a bed bath and
changed his gown. At first, he did not care what I
was doing, but as the day went on, I saw his smiles
sometimes and he said thank you to me more
often. Meeting physical needs (Maslow Hierarchy)
might be very effective in developing a trusting
relationship with patients.
Well-prepared:
I came to clinical well prepared. I knew all drugs
and labs my patients were having, what they are for,

Flexible
Coordinator of Care
Team Player
Educator
Ability to Prioritize
Knowledgeable

Areas Needing Growth-Include plan of

improvement
Client advocate:
Leadership:
I am working to become more assertive.

Technical skills:
I have not had many chances to do skills, so this is
an area I need to improve.
Critical thinking:
To get to this far (5th semester), I know I already
developed some degrees of critical thinking, but I
personally think it is not good enough to be
considered competent. I am working on it.

and why they were ordered. I read all available info

about my patient including H&P, Dx tests & results,
Progress notes, Nursing notes, etc...
Knowledgeable:
With your help, I think I gain more knowledge on
EKG and rhythm strips. Also, more knowledge on
Dx tests, what they were for, and why they were
ordered.
Instructor Comments:
Very nice job. You case map is very concise and you cover all topics that I want to see.
Excellent job. You are going to make a great nurse

Students Name: __Tuyet Nguyen___ Pts Initials: _J.A_

Date:_9/18-19__

Atrial rhythm: Regular

Ventricular rhythm: Regular

Atrial Rate__83_bpm____________

Ventricular rate ___83_bpm_________________

PR interval _0.16-0.18 sec________

QRS interval __0.08-0.10 sec______________

QT interval___0.36 sec__________
Is AV conduction normal? (Y/N)_Yes (slightly pointed), the PR interval is WNL__________
If not, why is it abnormal?
_______________________________________________________________________

P wave normal? (Y/N) __Yes_except occasional PVCs_____

QRS complex normal? (Y/N) _Yes except occasional PVCs_______
Are all of the QRS complexes the same? (Y/N) _Except occasional PVCs, underlying QRS
complexes are the same__________________
Are there premature beats? (Y/N) __Yes________ , Ventricular
Interpretation of rhythm:
__Underlying regular sinus rhythm with 2 occasional unifocal PVCs with a full compensatory
pause (within 6 second strip); Low voltage of QRS complexes__________________________
Potential hemodynamic consequences of this rhythm and interventions for this rhythm:
__PVCs may occur in healthy hearts, but are more common in coronary heart disease. Since the
patient is asymptomatic, no treatment may be indicated. However, the underlying cause of PVCs
should be treated because significant PVCs (more than 6 per minutes) increase risk for VT/VF.
__________________________GOOD
JOB____________________________________________

Student Name: ______Tuyet Nguyen____________ Date: __9/18/14__________

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 ___8__

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
Total Points

_________98____/100 = ____%