Case Study

CLINICAL WORKSHEET – NURSING CAREPLAN – Page 2

Pt. Initials _________ Student Name _______________________ Dates of Care _______________ Preceptor/Instructor___________________

NURSING INTERVENTIONS	EVALUATION	NURSING INTERVENTIONS	EVALUATION

Using the case study provided, you will complete the clinical worksheets that you will be using in the clinical courses for your clinical assignments.

a) Download the case study and all clinical paperwork.

b) Complete each form using the case study information.

    1) Medications-use the medication worksheet for each medication listed in the case study.  Each item on the form needs to be completed using your drug guide resource:  https://www.epocrates.com .  There should be at least one citation for this set of worksheets.  A completed example is provided in the attachments.

    2) Laboratory and Diagnostic results-there are two separate forms in the attachments for these results. 

      a)The lab results should all be added in the baseline column.  For any abnormal result, you must discuss the significance for the patient in that column.  Why is the lab result abnormal? A citation is required at the bottom of the worksheet.

      b) The diagnostic results-each column must be completed for each test that is discussed in the case study.  The reason ordered pertains to why would this diagnostic be ordered for this patient?  The significance is the analysis of the results.  Be thorough when discussing the significance.  A citation is required at the bottom of the worksheet.

   3) Vital Signs-include the vital signs on the care plan form under the appropriate assessment data-list of concepts.

   4) Care Plan-You need to complete 1 whole care plan based on case study.  This will include one nursing diagnosis with related to and as evidence by if applicable.  The nursing diagnosis should be ICNP approved.  This is noted in your required care plan book.  You will then add at least one expected outcome/measurable goal.  The final part of the care plan is to add 3 to 4 nursing interventions per expected outcome/goal listed.  If you add 3 expected outcomes, you will need 9-12 interventions.  The rationale needs to be included for each intervention.  Please make sure to include evaluations of each intervention and the goal.  This information is what you would expect after completing the intervention with the patient.  Please refer to the  Care Plan Example

Add 2 additional nursing diagnoses for this patient but you do not need the whole care plan completed for these 2.  You need an approved ICNP diagnosis, related to, and AEB. At least one citation should be included for the entire care plan section.

c) Complete assignment by the due date

Here is the Case Study to use for this assignment:  Case Study JP

This Required Assignment - the Charting and Care Plan are worth 50 points toward the theory grade.

Each of the worksheets are Word Documents-type all information and submit, please do not handwrite on any of these documents.**

Med (T) ______________________​​​​​​​​​​________PT. ALLERGIES _ ________________________________ PT Initials _______

(G) ___ __________________________ PT Diagnosis ______________________________________ Room ___________

Diagnosis Reason THIS patient is getting THIS med	Medication Info	Dosage	Contraindications	Adverse Reactions/ Major Side Effects	Nursing Considerations
	CLASS: USE: ACTION:	Recommended: Patient:	If applicable: Onset: Peak: Duration:		Therapeutic level ( Range:________________ Antidote/reversal agent: ( _____________________

Nursing 296 Transitions

Patient Situation

EHR

J.P is a 54-year-old male, 65”, 200 lbs., who appears to be 70. He has just been readmitted to General Hospital for the fifth time in 3 months. He is usually admitted for treatment of problems related to his severe COPD. He has been progressively short of breath. He has just started with an occasional cough productive of moderate amount of yellow sputum. His current temperature is 99.8. His history reveals no known allergies. He has difficulty voiding in the past with complaints of voiding frequently in small amounts and nocturia. He was diagnosed last year with Benign Prostatic Hypertrophy and underwent Transurethral Resection of the Prostate. He has suffered from Rheumatoid Arthritis for the last 5 years.

Because of his COPD, which greatly limits his physical exertion; J.P. is considered 100% disabled and has not worked for the past 8 years. In between hospital stays, he lives in a two-room apartment. He has a hot plate on which he cooks, but does not have a refrigerator. He shares a bathroom with ex-Navy buddies. In the hospital, J.P. is rather well-known and generally liked, because he is so familiar with the environment, he is often in an informal leadership position with new patients. His major complaint with the hospital is its non-smoking policy, strictly enforced.

Despite repeated teaching J.P. smokes, a pack and a half of unfiltered cigarettes a day. The basic physiology of his disease and its relationship have been explained to him repeatedly. He tells others that smoking is the only source of pleasure left to him. Whenever he is breathing easy enough, he walks to the sun room and lights a cigarette. “Live fast, love hard, die young---that’s my motto,” he frequently tells the nursing staff.

Upon exam J.P. states along with his other recent symptoms, he has not had much of an appetite and has been slightly nauseous. His doctor felt it was due to his medications. He has drunk 400 mL in the last 24 hours. He is alert and oriented x3, pupils are equal and reactive @3mm. He is HOH and wears glasses for reading. His color is dusky, skin is warm and dry. His resp are 26, regular with some use of shoulder and abdominal accessory muscles. O2 sat 88% RA. He always in orthopneic position in bed or in the chair. He is barrel chested and uses pursed lip breathing when he becomes SOB. Scattered rhonchi and expiratory wheezing are heard throughout both lung field. He has an occasional cough productive of a moderate amount of thick yellow sputum. His AP is 104 with 4 irregular beats per minute and a fair volume. BP 160/80. Bowel sounds are present in all 4 quadrants. His abdomen is soft and nondistended. Currently he has been voiding every 4-5h. His 24-hour urine output was 1000 mL (300 7-3, 400 3-11, and 300 11-7). His last BM was this AM-mod. soft brown BM. His lower extremities are pale and slightly cool to touch, Peripheral pulses are palpable bilaterally. Has 2+ pitting bilateral ankle edema. His hands, writs and feet are often painful and swollen due to arthritis. His joints are stiff especially in the AM.

Diet, Treatments and Medications

2gm Sodium Restricted Diet

02 @2L/M

CPT (Chest Physiotherapy) with postural drainage every 4 hours

Aerosol Albuterol Sulfate 2.5mg every 6 hours

Theophylline 300 mg every 12 hours PO

Prednisone 40mg PO Daily

Cefuroxime 750mg IV every 8 hours

Ibuprofen 300mg PO 4 times a day

Acetaminophen tabs 650mg PO or supp PRN for temp 101 or above

Ondansetron 4mg IV every 6 hours PRN

MOM 30 mL’s PO PRN

Terbutaline (Brethine) 0.3mg SQ every 3 hours PRN for SOB

Diagnostic Test Results:

CXR: Consistent with emphysematous blebs and cardiomegaly

EKG-Sinus Tachycardia

CBC-RBC 4.02 Hgb 11 Hct 32%

WBC 18,000

Segs 76% Bands 10% Eos 3% Basos 3%

Monos 10% Lymphs 24%

Sputum Culture-no growth

Theophylline Level-13.8

Lytes-NA 138 mEq

K 3.6 mEq

Cl 100 mEq

CO2 25mEq

Glucose 110

Cholesterol 200

BUN 20, Creatinine 1.0

Urinalysis

Appearance-clear Sp. Gr. 1.015 pH 6.2 color-amber

Protein-neg Glucose-neg Ketones-neg

Med (T) __Corgard ____________________​​​​​​​​​​________PT. ALLERGIES _ Morphine/PCN/Tylenol __ Pt initials ___JS____

(G) ___ Nadolol _____________________ PT Diagnosis Aspergillosis; Pneumonia; Hx of HTN __ Room ____210

Diagnosis Reason THIS patient is getting THIS med	Medication Info	Dosage	Contraindications	Adverse Reactions/ Major Side Effects	Nursing Considerations
patient has a history of HTN and has been on med for 18 months at home.	CLASS: Beta-Adrenergic Blocker USE: Used for mild to moderate hypertension or for chronic stable angina pectoris ACTION: Slows heart rate by decreasing cardiac output and decreasing B/P	Recommended: 40-80 mg tid up to 240-320mg/day Patient: 40 mg tid PO	If applicable: Onset: Peak: Duration:	Dizziness; Fatigue; Bradycardia	Tabs may be crushed; Assess B/P and Apical prior to giving; If pulse <60 or systolic B/P<90 hold med and call physician. May mask symptoms of hypoglycemia DO NOT suddenly stop med Cautious use with patients who have respiratory problems. Therapeutic level ( Range:________________ Antidote/reversal agent: ( _____________________

NURSING CAREPLAN

Student Name _______________________ Dates of Care ___________________ Preceptor/Instructor__________________

Pt. Initials ______________ List Patient Diagnosis/Surgical Procedures:

ASSESSMENT (Cluster Data)	NURSING DIAGNOSIS (Prioritized by Maslow) (List Source/Page #)	OBJECTIVES (Desired Outcomes/Goals) Must be measurable. List 2:	EVALUATION ( Outcome Criteria) Overall evaluation statements of goal. Met, partially met, not met. Include criteria AEB if partially or not met.
C = O= N= C= E= P= T= S=		1. 2.	1. 2.
		Nursing Actions: (Interventions)	Evaluation: (Evaluate Patients response to EACH action)