clinical judgement plan

N101L: Nursing Process Worksheet

Instructions: Each clinical day, the student will develop a nursing process outline for one patient of their choice. These will be discussed in clinical and in post-conferences with the faculty. Use the AAPIE Nursing Framework (Assess, Analyze, Plan, Implement, and Evaluate) for your assigned patient to complete the Patient Profile Database Worksheet and the Nursing Process Worksheet. Upload to CANVAS after the conference.

DIRECTIONS

What needs to be done:

Completed

If not, why?

Receive Handoff Report

Complete Head-to-Toe Assessment

Review patient chart:

· History and Physical

· Progress Notes

· Laboratory and Diagnostic Tests

· Vital Signs

· Medications

IDENTIFICATION DATA

Patient Initials: B.K.

Age: 69

Gender: Male

Allergies: The patient has no known allergies to drugs, food, latex, environmental, or herbal products

Isolation: None

Code Status:

· Full Code

· DNR

· Modified:

CHIEF COMPLAINT

“I have been experiencing repeated episodes of chronic cough, breathlessness, and frequent chest infections.”

ADMITTING DIAGNOSIS

Chronic obstructive pulmonary disease (COPD)

HISTORY OF PRESENT ILLNESS (HPI)

The client is a 69-year-old male who presented with a one-week history of frequent episodes of dyspnea with associated chronic cough and frequent chest infections. He has a long history of tobacco use, with a pack year score of 32. The patient reports that his dyspnea was of sudden onset and with diurnal variation. He states it was worse in the morning and was aggravated by mild exertion. The client also presented with a productive cough with clear mucoid sputum. The patient states that his cough was worse in the mornings and before going to bed. He also reports that he has been receiving treatment for recurrent chest infections over the past two months. He rates the severity of his symptoms as 7/10. He denies experiencing fever or unintentional weight loss.

PERTINENT PAST MEDICAL HISTORY (PMH)

· The patient denies being diagnosed with any chronic medical condition.

· He is currently not on any prescription, over-the-counter, or psychotropic medications.

· The client has a positive surgical history where he underwent open reduction and internal fixation after suffering a fracture in his left femur following a road traffic accident ten years ago.

Pathophysiology

Instructions: Provide a complete and detailed pathophysiology of the admitting diagnosis. Must include signs and symptoms, risk factors, and complications. Must relate the pathophysiology section back to the patient. Use academic, evidence-based references to support each criteria.

Pathophysiology of Admitting Diagnosis

Chronic obstructive pulmonary disease is a respiratory condition that results in airflow limitation. Airflow limitation can result from bronchitis or emphysema (Loscalzo et al., 2022). Bronchitis refers to chronic inflammation of the bronchus, leading to mucus production and cough. Conversely, emphysema is a lung disorder that leads to the destruction of alveoli and decreased lung function, leading to episodic dyspnea (MacLeod et al., 2021).

Emphysema is a small airway disease that predominantly accounts for the characteristic airflow obstruction in patients with COPD. In most cases, the inciting agent is tobacco smoke. Tobacco use in genetically susceptible individuals causes the recruitment of immune cells to the lungs. These cells include macrophages, neutrophils, lymphocytes, and epithelial cells. Once recruited, these cells release inflammatory mediators.

Moreover, biological pathways are also triggered. These include protease-antiprotease imbalance, oxidant-antioxidant imbalance, cell death, and ineffective lung repair (Loscalzo et al., 2022). All these processes combine to cause apoptosis, increased mucus production, and fibrosis.

Signs & Symptoms

The most common symptoms are:

· Cough

· Sputum

· Exertional dyspnea (Loscalzo et al., 2022)

The most commonly elicited signs include:

· Respiratory distress

· Nicotine staining on the fingernails of active smokers

· Central cyanosis

· Pursed lips breathing

· Lung hyperresonance on percussion

· Increased anterior-posterior chest wall diameter (Loscalzo et al., 2022)

Risk Factors

1. Cigarette smoking (MacLeod et al., 2021)

2. Genetic predisposition

3. Male gender

4. Occupational exposures

5. Environmental exposures

6. Passive or second-hand tobacco smoke exposure (Loscalzo et al., 2022)

Complications

· Acute respiratory failure

· Pulmonary hypertension (Rosenkranz et al., 2020)

· Cor pulmonale

· Recurrent pneumonias

· Acute exacerbations

Describe the relationship between the pathophysiology and the patient’s current condition in your own words (does not need citation)

Mr. B.K. is experiencing an acute exacerbation of chronic obstructive pulmonary disease. His presenting symptoms include a chronic cough, dyspnea, and airflow obstruction. These symptoms are the result of long-standing bronchitis and damage to his small airways following his chronic history of tobacco use. The cigarette smoke triggered the immune system and biological pathways that mediated the destruction of his alveoli. Immune cells such as macrophages and lymphocytes are critical in releasing inflammatory mediators that lead to apoptosis, impaired lung repair, and destruction of extracellular matrix. Conversely, biological pathways such as protease-antiprotease imbalance and oxidative stress contribute to chronic inflammation, increased mucus production, and lung fibrosis.

CURRENT VITALS AND DATA

HR: 83

RR: 22

Pain: 4/10

Height (cm): 175

Temp: 37.5 ˚C (oral)

BP: 120/77

SpO2: 88% on room air

Weight (kg): 62

ANALYSIS OF ASSESSMENT CUES

Instructions: In the space below, enter both subjective & objective data for all body systems gathered during your client assessment. Identify the top 3 priority body systems containing the assessment cues with cited explanations in relation to the patient and admitting diagnosis.

Body System

WNL or Abnormal

List of Abnormal Assessment Cues

Explanation of Abnormal Assessment Cues with evidence-based citations

Neuro

WNL- He denies loss of consciousness, altered mental status, or convulsions

Physical examination findings

The patient’s GCS score is 15/15. The mini-mental status examination is unremarkable. His speech is normal. Movement and coordination are intact. Motor and sensory functions are intact. Kerning’s and Brudzinski’s signs are negative.

Cardio

Abnormal- The client admits to palpitations

Physical examination findings

No palpable murmurs or parasternal heaves. S1 and S2 auscultated. Peripheral pulses are 2+. No carotid or abdominal aortic bruits.

Physical examination findings

1. An S3 murmur on auscultation

2. Displaced apex beat in the sixth intercostal space

The additional S3 murmur can be due to right-sided heart failure. COPD results in pulmonary hypertension, which predisposes individuals to right-ventricular failure, leading to a high-pitched systolic murmur due to tricuspid regurgitation (Rosenkranz et al., 2020).

The displaced apex beat is due to lung hyperinflation typically seen in COPD due to the destruction of small airways leading to emphysema.

Resp

Abnormal- He admits experiencing shortness of breath, chronic cough, and irregular breathing.

Physical examination findings

1. The chest wall is barrel-shaped

2. There is a prominent use of accessory respiratory muscles

3. Lung fields are hyper-resonant on percussion anteriorly and posteriorly

4. Decreased air entry with wheezing

The barrel-shaped chest wall and hyperresonance are due to

lung hyperinflation (Loscalzo et al., 2022).

The use of accessory respiratory muscles such as sternocleidomastoid, scalene, and intercostals is due to dyspnea. Patients typically assume a tripod posture to assist in ventilation (Loscalzo et al., 2022).

Reduced air entry results from the destruction of lung alveoli due to inflammatory and biological mechanisms.

GI

WNL- The client denies abdominal tenderness, nausea, vomiting, or diarrhea

Physical examination findings

The abdomen is slightly distended and non-tender. Bowel sounds are normoactive. There are no masses or hepatosplenomegaly on palpation.

GU

WNL- The patient denies voiding blood-stained urine, painful urination, or hesitancy

Physical examination findings

No abdominal flank pain on palpation. The kidneys are non-ballotable. Supra-pubic tenderness is absent. Urethral discharge absent

Skin

WNL- He denies changes in skin pigmentation, lesions, or pruritis

Physical examination findings

The patient’s skin is warm and dry. No dermatological lesions or skin pigmentation changes

Mobility

WNL- He denies limited range of joint motion, muscle weakness, or paralysis

Physical examination findings

The patient has no skeletal deformities. Joints in all extremities are non-tender and move through a full range of motion.

Safety

WNL- The patient is ambulant and has no individual or environmental risk factors that predispose him to risk of falls or injury.

Psych-Soc

WNL- The patient denies social isolation or experiencing anxiety, psychosis, mania, and depressive symptoms.

Pain

Abnormal- The client complains of pleuritic chest pain

Physical examination findings

1. Right-sided pleuritic chest pain

Pleuritic chest pain results from lung inflammation, leading to concurrent inflammation of the somatic pleura (Loscalzo et al., 2022).

ANALYSIS OF TOP 3 LABORATORY DATA/DIAGNOSTIC TESTS

Lab/Diagnostic Test

Date

Reference Range

Result

Why is this test necessary in relation to the patient’s admitting diagnosis? Use citations.

Complete blood count

07/15/2024

Hb: 13- 17 g/dl

WBC (×103/uL): 4.9 – 12.0

Hct: 33 – 45%

MCV: 80 – 95

Platelets (×103/uL): 140 - 450

Hb: 13

WBC: 14 (High)

Hct: 40

MCV: 83

Platelets: 380

A complete blood count is indicated to help diagnose anemia or the presence of concomitant infections (Loscalzo et al., 2022).

Anemia is defined as a reduced hemoglobin level below the normal ranges for age and gender. An elevated white cell count indicates infections.

Spirometry

07/15/2024

FEV1: 80% – 120%

FVC: 80%- 120%

FEV1/FVC: Within 5% of the predicted value

FEV1: 40%

FVC: 45%

FEV1/FVC: <0.7% of predicted

Spirometry is the gold-standard test for diagnosing COPD. Airflow obstruction in COPD is diagnosed with reduced FEV1 and FEV1/FVC (Haynes et al., 2023).

Arterial blood gas analysis

07/15/2024

pH: 7.35 – 7.45

PaO2: 70 -100 mmHg

PaCO2: 35 – 45 mmHg

pH: 7.35

PaO2: 63

PaCO2: 45

ABG analysis is indicated to help detect hypoxemia and provide additional information on alveolar ventilation and acid-base status (MacLeod et al., 2021).

MEDICATION LIST

Medication

Generic / Trade

Class

- Pharmacological

- Therapeutic

Purpose

(pertinent to patient)

Dose/Route/Time

(Frequency)

Mechanism

of Action

Common

Side Effects

Nursing Considerations

Combivent Respimat

A combination medication containing ipratropium bromide (muscarinic antagonist)/albuterol (short-acting beta agonist)

To provide acute relief of the patient’s dyspnea and impaired ventilation.

Each 2.5ml single dose unit contains 500 mcg of ipratropium bromide and 3mg salbutamol sulfate.

Route: Inhalation

Frequency: Four hourly

Muscarinic antagonists like ipratropium bromide prevent cholinergic nerve-induced bronchoconstriction.

Short-acting beta agonists like albuterol activate beta 2-adrenergic receptors, leading to the relaxation of smooth muscle cells and bronchodilation.

1. Xerostomia

2. Urinary retention

3. Glaucoma

1. Muscle tremors

2. Palpitations

a. Ensure the face mask fits properly

b. Check for abdominal distention

c. Reassure the patient

Clindamycin

Antibiotic

Treat patient’s infection

Dose: 300mg

Route: Oral

Frequency: Six hourly

Inhibits bacterial protein synthesis

1. Gastrointestinal dysfunction

2. Skin rash

3. Neutropenia

a. Monitor for adverse drug events

b. Monitor hepatic function

Levofloxacin

Antibiotic

Treat patient’s infection

Dose: 500mg

Route: Oral

Frequency: Once daily

Inhibits bacterial DNA synthesis

1. Nausea, vomiting, diarrhea

2. Headache

3. Skin rash

a. Assess for drug side effects

b. Monitor renal and liver functions

Paracetamol

Analgesic

Manage the patient’s pain

Dose: One gram

Route: Intravenously

Frequency: Eight hourly

Prevents prostaglandin synthesis through inhibition of cyclooxygenase isoenzymes

1. Nausea

2. Vomiting

3. Abdominal pain

4. Jaundice

a. Monitor injection site for pain or prolonged swelling

b. Observe for adverse drug effects

c. Respect patient’s rights

d. Reassure the patient

PRIORITY HYPOTHESIS/PROBLEM

Using the pertinent abnormal cues, choose 1 priority hypothesis

Impaired gaseous exchange in the lung alveoli.

SMART GOAL

Goal must be Specific, Measurable, Attainable, Realistic, and Timestamped.

Start goal statement with, “Patient will... by...”

The patient will maintain SpO2 stats above 94% on room air by the end of my shift.

IMPLEMENTATION

For the identified priority hypothesis/problem, provide 4 independent interventions (1 must be a teaching intervention). All interventions must have a rationale supported with evidence-based citations.

1. Administer supplemental oxygen

Rationale: Oxygen should be administered to help prevent hypoxemia (MacLeod et al., 2021). Usually, a low concentration of about 1-4 /min is indicated via nasal cannula.

2. Administer medications

Rationale: Nebulization with a short-acting beta-agonist and muscarinic antagonist are indicated first-line therapies in managing acute COPD exacerbations (Loscalzo et al., 2022). These drugs work by dilating the airway, thus reducing airflow obstruction and improving ventilation.

3. Encourage pursed-lip breathing

Rationale: Pursed-lip breathing helps reduce anxiety symptoms and reduces the respiratory rate. This breathing technique helps deliver oxygen to the lungs while removing retained carbon dioxide (Yang et al., 2022).

4. Educate the client on how to prevent as well as recognize acute exacerbations of symptoms

Rationale: Acute COPD exacerbations are linked to worse outcomes and often increase treatment costs due to hospitalization. Educating the client to avoid triggers of acute exacerbations like environmental pollutants, respiratory infections, or allergies can help prevent exacerbations (MacLeod et al., 2021). Additionally, the patient should be instructed on recognizing an acute exacerbation through increased breathlessness, coughing or sputum production and the need to contact their healthcare provider.

EVALUATION

Select whether your goal was met, partially met, or not met. If goal was met, explain why. If goal was partially met or not met, must include revisions.

· Goal Met

Why the goal was met:

· Supplemental oxygen was administered

· Nebulization with Combivent every four hours helped provide relief from breathlessness and improved ventilatory function.

· Goal Partially Met

Revision(s):

· Goal Not Met

Revision(s):

NURSING APPLICATION ASSESSMENT

Instructions: Include activities throughout the day performed in relation to the following NCLEX content categories. See content category below for examples from the NCSBN.

Management of Care Nursing treatments provided to patient to help disease or medical problem/s

1. I served as the patient’s advocate by providing patient education, explaining diagnostic investigations and treatment therapies, and working with the interdisciplinary team to enhance the client’s health outcome. I delegated tasks such as monitoring of vitals to on-duty licensed practical nurses. Educated the patient on his rights and ensured strict adherence to HIPAA guidelines in the care of the patient.

Safety and Infection Control Measures done to keep patient and you are safe, to prevent infection and worse condition

2. The client’s room was cleared of any obstacles to prevent falls. To avoid infection transmission, the following interventions were applied: regular sanitization before contact with the patient and use of personal protective equipment. Hazardous materials like sharps were disposed in a sharps container.

Basic Care and Comfort Nursing measures given to patient to keep clean and comfortable

3. The patient adequately performed all activities of daily living by himself. The client did not have impaired elimination function. He was ambulating and did not require any mobility aids.

STUDENT JOURNAL

Personal goals for the day

What clinical objectives did you focus on today?

1. Perform head-to-toe assessments of all assigned patients

2. Strengthen critical thinking skills and clinical decision-making competencies

3. Appropriately implement nursing care to enhance positive patient outcomes

Experience (specialty areas) and activities of the day

What new skills or procedures did you witness or participate/assist with?

1. I assisted in wound care

2. Administered intravenous medication

3. Performed urinary catheterization

Thoughts about your experience today

How did you meet your goal? Do you have any preconceived notions that changed?

I achieved my established goals by ensuring I held myself accountable. Additionally, I set few and specific goals that I could accomplish easily. Regarding having any preconceived assumptions, I always try to have an open-minded approach to situations. So, during my experience, no presumptions were changed.

Your feelings about today

How can you utilize your experience in the future?

Today’s clinical experience has been thoroughly educative. I got to actively participate in taking care of patients. I gained competencies in applying the nursing process to patient care. The clinical skills honed throughout my day will assist me as a future registered nurse in providing optimal care to enhance positive patient outcomes.