Fundamental

Ceyong

a year ago
21.09.2025
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templateRUAFUNDAMENTAL.pdf

RUASBARCOPD.docx

templateRUAFUNDAMENTAL.pdf

NR226 Fundamentals – Patient Care RUA Template

Success note: Follow APA guidelines and include intext citations, a title page and a reference page. In the title page, include the title of the RUA, student name, name of school, number/name of course, instructor name and assignment due date. Please delete this success note when submitting.

Introduction of Disease

Age and reason for hospitalization (medical diagnosis): Nursing concept that is connected to reason for hospitalization: Brief review of underlying pathophysiology:

Functional changes that can happen as part of the disorder. Complications that can happen as part of the disorder. Scholarly in text citation(s) to support information.

Safety-Communication-Infection Control

Communication elements: Safety concerns: Infection control practices:

Assessment: Recognize/Identify cues

Identified cues:

• Cue 1

• Cue 2 • Cue 3 • Cue 4

• Psychosocial Cue

Nursing Diagnosis: Analyze Cues/ Prioritize Hypothesis

Cue/ area of concern that is high priority: Cue/ area of concern that is medium priority: Cue/ area of concern that focuses on psychosocial problem/need: Rationale for why these areas of concern/cues were chosen and prioritized as high, medium or psychosocial and how they connect to the client:

Planning: Generating Solutions and

Implementation: Taking Action

Cue/area of concern that is high priority: S.M.A.R.T. goal:

Rationale for goal: Client specific intervention:

Cue/area of concern that is medium priority:

S.M.A.R.T. goal: Rationale for goal: Client specific intervention:

Cue/area of concern that is psychosocial:

S.M.A.R.T. goal: Rationale for goal: Client specific intervention:

Evaluation: Evaluating Outcomes

Explain if goals were met or not: Supportive evidence: Changes needed to achieve goals in the future:

References

RUASBARCOPD.docx

I-SBAR
I – Introduce Yourself	Your Name:
	D#:
	Your Title: Nursing Student
	Reason for being there: Clinical rotation, patient assessment
S – Situation	Patient: M. R.	Attending Physician: Dr. Johnson, Pulmonology
	Age: 67 years old	Patient Chief Complaint/Primary Medical Diagnosis and Clinical Significance: Admitted for acute exacerbation of COPD with increased dyspnea, productive cough with purulent sputum, and decreased exercise tolerance. Risk for respiratory failure, pneumonia and potential right heart failure (cor pulmonale).
	Gender/Identity: Female
	Height/Weight: 5’4” (163cm) / 156 lbs. (70.8 kg)
	Allergies : Penicillin (rash), Codeine (nausea)
	Code Status: Full
	Advance Directive (durable power of attorney, living will, other) and Clinical Significance: DNR discussed but not implemented	Pathophysiology of Primary Medical Diagnosis: COPD is a progressive, irreversible airway disease characterized by chronic inflammation, airway obstruction, and alveolar destruction. Leads to impaired gas exchange, increased work of breathing, ventilation-perfusion mismatch, and potential right heart failure (cor pulmonale).
	Privacy Code: 7892
	Date of Care/Time: 9/01/2025 - 0800
B – Background	Include clinical significance with each:
	Past Medical History: COPD (diagnosed 15 years ago, moderate-severe) · Hypertension · Type 2 diabetes mellitus · History of pneumonia (2 episodes in past 2 years) · Osteoporosis (related to chronic steroid use)	Past Surgical History: Cholecystectomy (age 45) Cataract surgery bilateral (ages 62, 64)
	Immunizations Received: Up to date with influenza vaccine, pneumococcal vaccine received 2 years ago, COVID-19 vaccines current
	Social History/Socioeconomic Factors: Former smoker (40 pack-year history, quit 5 years ago), lives with husband who is primary caregiver, retired secretary, Medicare coverage, daughter lives nearby for support. History of frequent hospitalizations affecting quality of life.
A – Assessment	Vital Signs:
	B/P	HR	RR	TEMP	SP02	PAIN
	148/92 mmHg	98 bpm	28/min	100.2°F (37.9°C)	88% on 2L O2	3/10 chest tightness

	Fall Risk: High (weakness, orthostatic hypotension, steroid-Induced muscle weakness)	Accu-check: 156 mg/dL
	IV Site: 22g R forearm, patent, site clean/dry	IV Fluids: NS @ 75 mL/hr	Lab/Test Results: ABG: pH 7.32, PCO₂ 58 mmHg (↑), PO₂ 62 mmHg (↓), HCO₃ 28 mEq/L (compensated respiratory acidosis) CBC: WBC 11.8 (↑), Hgb 16.2 g/dL (↑ secondary polycythemia), Hct 48% (↑) BNP: 450 pg/mL (↑, suggesting right heart strain) Theophylline level: 12 mcg/mL (therapeutic) Sputum culture: Pending
I and O	Intake 1.2 L IV + 800 mL PO; Output 1400 mL urine in past 24 hr
Isolation	Isolation Precautions: Y ☐ N ☒	Contact Air ☐ Droplet ☐
RESPIRATORY	Diminished breath sounds bilaterally, expiratory wheeze throughout, use of accessory muscles, barrel chest, pursed-lip breathing, productive cough with thick yellow-green sputum
CARDIOVASCULAR	Regular rhythm, distant heart sounds, peripheral edema 1+ bilateral ankles. JVD at 30 degrees, possible S3 gallop
NEUROLOGICAL	Alert but anxious, oriented x3, reports feeling "air hungry," mild confusion episodes during night (CO₂ retention)
GI/GU	Decreased appetite, reports early satiety, bowel sounds present, voiding without difficulty, concerned about weight loss over past months
INTEGUMENTARY	Pale with slight cyanosis around lips and fingernails, skin intact, poor skin turgor suggesting mild dehydration, digital clubbing noted
PSYCHOLOGICAL FAMILY – SUPPORT	Husband at bedside frequently, daughter visits daily. Patient expresses frustration with declining functional status and fear of "suffocating." Reports depression related to lifestyle limitations
SAFETY	Teaching needed: Proper inhaler technique, energy conservation techniques, smoking cessation support (for husband who still smokes), oxygen safety, recognition of exacerbation symptoms, importance of medication compliance. Oxygen in use - fire safety precautions, call light within reach, bed low, non-slip socks, fall precautions in place
R – REQUEST/ RECOMMENDATION	Hand off report to: Nursing Student	From: RN

templateRUAFUNDAMENTAL.pdf

NR226 Fundamentals – Patient Care RUA Template

Introduction of Disease

Age and reason for hospitalization (medical diagnosis): Nursing concept that is connected to reason for hospitalization: Brief review of underlying pathophysiology:

Functional changes that can happen as part of the disorder. Complications that can happen as part of the disorder. Scholarly in text citation(s) to support information.

Safety-Communication-Infection Control

Communication elements: Safety concerns: Infection control practices:

Assessment: Recognize/Identify cues

Identified cues:

• Cue 1

• Cue 2 • Cue 3 • Cue 4

• Psychosocial Cue

Nursing Diagnosis: Analyze Cues/ Prioritize Hypothesis

Planning: Generating Solutions and

Implementation: Taking Action

Cue/area of concern that is high priority: S.M.A.R.T. goal:

Rationale for goal: Client specific intervention:

Cue/area of concern that is medium priority:

S.M.A.R.T. goal: Rationale for goal: Client specific intervention:

Cue/area of concern that is psychosocial:

S.M.A.R.T. goal: Rationale for goal: Client specific intervention:

Evaluation: Evaluating Outcomes

Explain if goals were met or not: Supportive evidence: Changes needed to achieve goals in the future:

References

RUASBARCOPD.docx

I-SBAR
I – Introduce Yourself	Your Name:
	D#:
	Your Title: Nursing Student
	Reason for being there: Clinical rotation, patient assessment
S – Situation	Patient: M. R.	Attending Physician: Dr. Johnson, Pulmonology
	Age: 67 years old	Patient Chief Complaint/Primary Medical Diagnosis and Clinical Significance: Admitted for acute exacerbation of COPD with increased dyspnea, productive cough with purulent sputum, and decreased exercise tolerance. Risk for respiratory failure, pneumonia and potential right heart failure (cor pulmonale).
	Gender/Identity: Female
	Height/Weight: 5’4” (163cm) / 156 lbs. (70.8 kg)
	Allergies : Penicillin (rash), Codeine (nausea)
	Code Status: Full
	Advance Directive (durable power of attorney, living will, other) and Clinical Significance: DNR discussed but not implemented	Pathophysiology of Primary Medical Diagnosis: COPD is a progressive, irreversible airway disease characterized by chronic inflammation, airway obstruction, and alveolar destruction. Leads to impaired gas exchange, increased work of breathing, ventilation-perfusion mismatch, and potential right heart failure (cor pulmonale).
	Privacy Code: 7892
	Date of Care/Time: 9/01/2025 - 0800
B – Background	Include clinical significance with each:
	Past Medical History: COPD (diagnosed 15 years ago, moderate-severe) · Hypertension · Type 2 diabetes mellitus · History of pneumonia (2 episodes in past 2 years) · Osteoporosis (related to chronic steroid use)	Past Surgical History: Cholecystectomy (age 45) Cataract surgery bilateral (ages 62, 64)
	Immunizations Received: Up to date with influenza vaccine, pneumococcal vaccine received 2 years ago, COVID-19 vaccines current
	Social History/Socioeconomic Factors: Former smoker (40 pack-year history, quit 5 years ago), lives with husband who is primary caregiver, retired secretary, Medicare coverage, daughter lives nearby for support. History of frequent hospitalizations affecting quality of life.
A – Assessment	Vital Signs:
	B/P	HR	RR	TEMP	SP02	PAIN
	148/92 mmHg	98 bpm	28/min	100.2°F (37.9°C)	88% on 2L O2	3/10 chest tightness

	Fall Risk: High (weakness, orthostatic hypotension, steroid-Induced muscle weakness)	Accu-check: 156 mg/dL
	IV Site: 22g R forearm, patent, site clean/dry	IV Fluids: NS @ 75 mL/hr	Lab/Test Results: ABG: pH 7.32, PCO₂ 58 mmHg (↑), PO₂ 62 mmHg (↓), HCO₃ 28 mEq/L (compensated respiratory acidosis) CBC: WBC 11.8 (↑), Hgb 16.2 g/dL (↑ secondary polycythemia), Hct 48% (↑) BNP: 450 pg/mL (↑, suggesting right heart strain) Theophylline level: 12 mcg/mL (therapeutic) Sputum culture: Pending
I and O	Intake 1.2 L IV + 800 mL PO; Output 1400 mL urine in past 24 hr
Isolation	Isolation Precautions: Y ☐ N ☒	Contact Air ☐ Droplet ☐
RESPIRATORY	Diminished breath sounds bilaterally, expiratory wheeze throughout, use of accessory muscles, barrel chest, pursed-lip breathing, productive cough with thick yellow-green sputum
CARDIOVASCULAR	Regular rhythm, distant heart sounds, peripheral edema 1+ bilateral ankles. JVD at 30 degrees, possible S3 gallop
NEUROLOGICAL	Alert but anxious, oriented x3, reports feeling "air hungry," mild confusion episodes during night (CO₂ retention)
GI/GU	Decreased appetite, reports early satiety, bowel sounds present, voiding without difficulty, concerned about weight loss over past months
INTEGUMENTARY	Pale with slight cyanosis around lips and fingernails, skin intact, poor skin turgor suggesting mild dehydration, digital clubbing noted
PSYCHOLOGICAL FAMILY – SUPPORT	Husband at bedside frequently, daughter visits daily. Patient expresses frustration with declining functional status and fear of "suffocating." Reports depression related to lifestyle limitations
SAFETY	Teaching needed: Proper inhaler technique, energy conservation techniques, smoking cessation support (for husband who still smokes), oxygen safety, recognition of exacerbation symptoms, importance of medication compliance. Oxygen in use - fire safety precautions, call light within reach, bed low, non-slip socks, fall precautions in place
R – REQUEST/ RECOMMENDATION	Hand off report to: Nursing Student	From: RN

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