Assignment: Assessment 1
M, L

Health Care Provider: A P

Sex: M

Weight: 255 lbs 12 oz

Code Status: 02

Isolation: 00

Food Allergies: 00

Diet: 01

Hospital Floor:

Age: 62 Y

Height: 6'

Alerts: 00

Drug Allergies: 00

Env. Allergies: 00

BMI: 34.7

Medical-Surgical

Student: Marlen Flores Assignment: Assessment 1 Submitted: 02/16/2016 15:49
Clinical Assignment Grading
Assignment Objectives
No assignment objectives entered.
Clinical Set-up Details
First Day of Clinical:

02/10/2016

Primary Diagnosis:

Chronic obstructive pulmonary disease
(COPD)

Provider Name:

P, A

Secondary Diagnosis:

Student Details:

Patient Details:

First Initial:

M

Identifier 1: L

Last Name:

Flores

Identifier 2: M

Credentials:

SNPC

Gender:

M

Age:

62 Years

Pre-Clinical Manager
Patient Info Identifier: M, L

Gender: M

Age: 62 Y

Nurse Initials: M Flores, SNPC

Diagnosis (1)
Primary Diagnosis:

Chronic obstructive pulmonary disease (COPD)

Patho-Physiology:
A progressive disease that is associated with difficulty breathing due to severe injuries to the pulmonary alveoli. The cause of this disease is the continuous exposure to cigarette smoke either actively or passively, and contaminated environments which reduces the shortness of breath and chest tightness. COPD may appear as two distinct disorders: emphysema and chronic bronchitis. Emphysema is the broadening of the alveoli and the destruction of their walls.
Chronic bronchitis is manifested as a chronic persistent cough that produces sputum and it is not due to an apparent clinical cause, like lung cancer, but rather the dilation of the bronchial glands that causes excessive mucus secretion.
Both diseases are closely linked and often occur simultaneously, or one ends up causing the other.
Therapeutic Regimen:
-Current Health Problems and Related Functional Changes:
-Medications (1)
Medication:Amiodarone Tablet - (Cordarone, Pacerone)

Classification:
Cardiovascular agent: antiarrhythmic

Route:
Oral
Frequency:QAM

Dose:
Date
Ordered:

Comments and Additional Medication Info:

Therapeutic Effect:

100 mg
02/10/2016

--

By direct action on smooth muscle, decreases peripheral resistance and increases coronary blood flow. Blocks effects of sympathetic stimulation.

Action:

Contraindications:

Structurally related to thyroxine. Class III antiarrhythmic;

Hypersensitivity to amiodarone, or benzyl alcohol;

also has antianginal and antiadrenergic properties.
Totally unrelated to other antiarrhythmics. Acts directly

cardiogenic shock, severe sinus bradycardia, advanced
AV block unless a pacemaker is available, severe sinus-

on all cardiac tissues. Prolongs duration of action

node dysfunction or sick sinus syndrome, bradycardia,

potential and refractory period without significantly

congenital or acquired QR prolongation syndromes, or

affecting resting membrane potential.

history of torsade de pointes; severe liver disease, children. Safety during pregnancy (category D) or lactation is not established.

Side Effects or Adverse Reactions:

Life Threatening Considerations:

CNS: Peripheral neuropathy (muscle weakness, wasting

--

numbness, tingling), fatigue, abnormal gait, dyskinesias, dizziness, paresthesia, headache. CV: Bradycardia, hypotension (IV), sinus arrest, cardiogenic shock, CHF, arrhythmias; AV block. Special Senses: Corneal microdeposits, blurred vision, optic neuritis, optic neuropathy, permanent blindness, corneal degeneration, macular degeneration, photosensitivity. GI: Anorexia, nausea, vomiting, constipation, hepatotoxicity.
Metabolic: Hyperthyroidism or hypothyroidism; may cause neonatal hypo- or hyperthyroidism if taken during pregnancy. Respiratory: (Pulmonary toxicity) Alveolitis, pneumonitis (fever, dry cough, dyspnea), interstitial pulmonary fibrosis, fatal gasping syndrome with IV in children. Skin: Slate-blue pigmentation, photosensitivity, rash. Other: With chronic use, angioedema.
Recommended Dose Ranges:
200 mg tablets; 50 mg/mL injection

Nursing Interventions:
--

Clinical Grading:
Clinical
Grade:
Remarks:
Care Plan Details
Care Plan
Priority
1

Medical Diagnosis: Chronic obstructive pulmonary disease (COPD)
Modified By: M Flores, SNPC 02/15/2016 |
21:07

Status:

Active

Related To
Ventilation-perfusion imbalance

Created By: M Flores, SNPC 02/13/2016 | 01:29
Nursing Diagnosis: Impaired gas exchange

Type:
Actual

Evidenced By
Abnormal arterial blood gases
Abnormal breathing
Confusion
Cyanosis
Dyspnea
Hypoxemia
Restlessness

Expected Outcome

Measurement/Time

Comments

Frame
Patient will demonstrate improved ventilation and adequate

by discharge

oxygenation, as evidenced by blood gas levels within normal parameters for that patient.
ADDED-Patient will maintain 02 sat over 90% by end of shift.

by end of shift

Interventions

Rationale

Comments

Administering humidified oxygen through an appropriate device

may correct or prevent worsening of hypoxia.

Auscultating breath sounds

breath sounds may be faint because airflow or areas of consolidation.

Helping the patient perform deep breathing and controlled coughing

patient understands the appropriate technique s to keep airway of secretions.

Monitoring oxygen saturation

ensure proper ventilation and tissue perfussio n Monitoring respiratory rate, depth, and ease of respiration

evaluate the degree of respiratory distress

Observing the patient for cyanosis

may be a sign of advanced hypoxemia.

ADDED-Palpate for fremitus

decrease of vibratory tremors suggests fluid c ollection or air-trapping.

ADDED-Monitor anxiety

can be indicative of hypoxia.

ADDED-Collaborate with x-ray technician for chest x-ray

reveal changes indicative of increase/resolutio n of pulmonary congestion

ADDED-Teach patient to use incentive spirometer to prevent atelectasis and improve lung capaci ty. Priority
2

Medical Diagnosis: Chronic obstructive pulmonary disease (COPD)

Status:

Active

Related To
Generalized weakness
Imbalance between oxygen supply and oxygen demand
Evidenced By

Created By: M Flores, SNPC 02/13/2016 | 02:32
Nursing Diagnosis: Activity intolerance
Type:
Actual

Verbal report of fatigue
Verbal report of weakness
ADDED-dyspnea and tachycardia

Expected Outcome

Measurement/Time Frame

Patient will demonstrate increased tolerance of activity.

by discharge

ADDED-Patient will report decreased fatigue by

end of shift

Interventions

Rationale

Allowing for periods of rest before

rest decreases myocardial oxygen consumption, allo

and after planned periods of

wing intervals of low energy demand. Decreased oxy

exertion

Comments

Comments

gen consumption allows more oxygen to be available for ventilation.

ADDED-Assess and monitor patient’s response to activity (vital signs, dyspnea, signs of exertion

to establish patient’s capabilities and needs and facil itate interventions.

ADDED-Provide a quiet environment and limit visitors during acute phase

reduces stress and excess stimulation, promoting res
t.

ADDED-Assist with activities of daily living as needed

minimize exhaustion and help to balance oxygen and demand. ADDED-Teach patient to recognize signs of physical over activity-

promotes awareness of when to reduce activity.

ADDED-Monitor patient’s sleep pattern and amount of sleep achieved over past few days

sleeping deprivation needs to be addressed before a ctivity progression can be achieved.

Priority
--

Medical Diagnosis: Chronic obstructive pulmonary disease (COPD)
Deleted By: M Flores, SNPC 02/13/2016 | 02:26

Status:

Deleted

Created By: M Flores, SNPC 02/13/2016 | 02:22
Nursing Diagnosis: Impaired gas exchange

Type:
Actual

Related To
ADDED-imbalance between oxygen supply and demand
ADDED-general weakness
ADDED-exhaustion associated with dyspnea
Evidenced By
Dyspnea
Tachycardia
ADDED-verbal reports of weakness and fatigue

Expected Outcome

Measurement/Time
Frame

ADDED-Patient will report decreased fatigue

end of shift

Comments

ADDED-Patient maintains activity level within capabilities, as

discharge

evidenced by normal heart rate and blood pressure during activity, as well as absence of shortness of breath, weakness, and fatigue.
Interventions

Rationale

Comments

Considering the use of a wheeled walker to help in ambulation

requires less effort and less exhaustion for patient wh en ambulating.

Teaching the patient energy-

promotes awareness of when to reduce activity.

conservation techniques
ADDED-• Assess and monitor patient’s response to activity (vital

to establish patient’s capabilities and needs and facil itate interventions.

signs, dyspnea, signs of exertion)ADDED-Assist the patient in

rest decreases myocardial oxygen consumption, allo

sequencing activities to provide for

wing intervals of low energy demand. Decreased oxy

rest periods

gen consumption allows more oxygen to be available for ventilation.

ADDED-Provide a quiet environment and limit visitors during acute phase

reduces stress and excess stimulation, promoting re st. Care Plan Grading:
Care Plan
Grade:
Remarks:
Charting Details
System Assessments
Cardiovascular Assessment

Created By: M Flores, SNPC 02/10/2016 | 17:52

Pulses
Apical:
Murmur noted:

Regular
No

Carotid Pulse
Left Carotid Pulse:
Murmur noted:
Right Carotid Pulse:
Murmur noted:

2+ Expected
No
2+ Expected
No

Peripheral Pulse
Left Brachial Pulse:
Pulse:
Right Brachial Pulse:
Pulse:
Left Radial Pulse:
Pulse:
Right Radial Pulse:
Pulse:

2+ Expected
Regular
2+ Expected
Regular
2+ Expected
Regular
2+ Expected
Regular

Left Femoral Pulse:

2+ Expected

Pulse:

Regular

Right Femoral Pulse:

2+ Expected

Pulse:

Regular

Left Popliteal Pulse:
Pulse:

2+ Expected
Regular

Right Popliteal Pulse:

2+ Expected

Pulse:

Regular

Left Posterior Tibial Pulse:
Pulse:

2+ Expected
Regular

Right Posterior Tibial Pulse:

2+ Expected

Pulse:

Regular

Left Dorsalis Pedis Pulse:

2+ Expected

Pulse:

Regular

Right Dorsalis Pedis Pulse:

2+ Expected

Pulse:

Regular

Tissue Perfusion
Peripheral vascular, general:

Warm extremities

Edema
No edema noted
Capillary Refill
Left hand:
Left foot:
Right hand:
Mucous membranes color:
Mucous membranes moisture:

Less than 3 seconds
Less than 3 seconds
Less than 3 seconds
Pink
Moist

Cardiac Assessment
Dyspnea on exertion
Telemetry
Continuous telemetry:
Alarms tested:

No
No

Respiratory Assessment

Created By: M Flores, SNPC 02/10/2016 | 17:56

Respiratory Pattern
Labored
Shallow
Respiratory Effort
Dyspnea/shortness of breath
Upper Right Anterior
Auscultation:

Diminished

Upper Left Anterior
Diminished

Left Lateral
Wheeze
Wheeze Description:

Throughout

Right Lateral
Auscultation:

Wheeze

Wheeze Description:

Throughout

Upper Left Posterior
Auscultation:

Wheeze

Wheeze Description:

Throughout

Upper Right Posterior
Auscultation:

Wheeze

Wheeze Description:

Throughout

Lower Left Posterior
Auscultation:

Diminished

Lower Right Posterior

Respiratory Pattern and Breath
Sounds Notes:

Diminished bilateral wheezing

Oxygenation

Amount of oxygen in L/min:
Oxygenation evaluation:
Oxygen delivery system:
Respiratory/breathing support:

Oxygen in use
2.5
Continuous pulse oximetry
Nasal Cannula
Incentive spirometer

Cough
Cough type:
Cough strength:

Dry
Weak

Neurological Assessment

Created By: M Flores, SNPC 02/10/2016 | 18:00

Level of Consciousness/Orientation
Oriented to person, place, time, and situation
Emotional State
Calm
Cooperative
Hand Grip
Bilateral assessment:
Left hand grip strength:
Right hand grip strength:

Equal
Strong
Strong

Foot Pumps
Bilateral assessment:

Equal

Left foot strength:

Strong

Right foot strength:

Strong

Central Nervous System Assessment (CNS)
No CNS problems evident
CNS Notes:

No acute neurological facial deficit

Glasgow Coma Scale

Created By: M Flores, SNPC 02/10/2016 | 18:01

Eye Opening Response
Degree to which patient is able to

Spontaneous = 4 Spontaneously opens eyes

open eyes:
Best Motor Response
Degree to which patient is able to control motor movements:

Obeys Motor Command = 6 Able to control motor movements such as 'Hold out 3 fingers'

Best Verbal Response
Degree to which patient is able to converse with others:

Oriented and converses = 5 Able to converse with others

Glasgow Score
Total Glasgow Score =
Integumentary Assessment

15
Created By: M Flores, SNPC 02/10/2016 | 18:04

Skin Assessment
Color:
Skin turgor:
Temperature:
Integrity:
Moisture:
Skin Notes:

Within expected parameters for patient
Good elasticity
Warm
Intact skin, no lesions
Moist
no rash

Hair Assessment
Distribution:
Health:
Characteristics:

Expected for sex
Healthy
Expected hair throughout

Nail Assessment
Configuration:
Condition:
Color:
Nail base:
Braden Scale

Smooth and intact
Healthy appearance, well groomed
Pink
Flat and smooth

Sensory Perception
Ability to respond meaningfully to pressure-related discomfort:

Moisture

NO IMPAIRMENT = 4 Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. Degree to which skin is exposed to

RARELY MOIST = 4 Skin is usually dry. Linen only requires

moisture:

changing at routine intervals.

Activity
Degree of physical activity:

WALKS OCCASIONALLY = 3 Walks occasionally during day, but for short distances, with or without assistance. Spends majority of each shift in bed or chair.

Mobility
Ability to change and control body

NO LIMITATION = 4 Makes major and frequent changes in

position:

position without assistance.

Nutrition
Usual food intake pattern:

ADEQUATE = 3 Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day.
Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs.

Friction and Shear
Degree to which skin is at risk for friction or shearing wounds:

NO APPARENT PROBLEM = 3 Moves in bed and chair independently and has sufficient muscle strength to lift up completely during move.Maintains good position in bed or chair. Total Braden Scale Pressure Score Risk Factor
Total Braden Scale Score

21
Not at Risk

Sensory Assessment

Created By: M Flores, SNPC 02/10/2016 | 18:05

Vision Assessment
No major vision problems noted
Wears glasses
Hearing Assessment
No hearing problems noted
Pupillary Equality
Bilateral assessment:

Equal

Pupillary Reaction
Left eye reaction to light:
Right eye reaction to light:

Brisk
Brisk

Pupillary Accommodation
Accommodation present?
Musculoskeletal Assessment
Range of Motion (ROM)

Yes
Created By: M Flores, SNPC 02/10/2016 | 18:06

Moves all extremities with full range of motion
Gait/Balance
Ambulates on own, steady gait
Gastrointestinal Assessment

Created By: M Flores, SNPC 02/10/2016 | 18:08

Mouth/Gums/Teeth
Gums and mouth:
Teeth/bridges/dentures:

Good condition, no lesions or sores
Teeth in good condition

Esophageal
Esophageal assessment:

Frequent heartburn

Abdomen
Abdominal assessment:

Rounded
Nontender to palpation

Gastrointestinal
No gastric problems noted
Intestinal
Date of last bowel movement:
Intestinal assessment:
Bowel sounds:
Stool characteristics:
Rectum:

02/069/2016
No bowel problems noted
Active x 4 quadrants
Loose
No reported rectal problems

Genitourinary Assessment

Created By: M Flores, SNPC 02/10/2016 | 18:08

Urinary System Assessment
Urination mode:

Voiding

Urine Color/Characteristics
Color:
Urinary Assessment:
Characteristics:
Odor:

Pale yellow
No urinary incontinence
Clear
No odor

Male
Penis assessment:
Scrotum/testes assessment:

No problems noted
No problems noted

Pain Assessment

Created By: M Flores, SNPC
02/10/2016 | 18:10

Do You Have Pain Now?
Yes
Location of Pain:

Chest
Frequency of Pain:
Intermittent
Intensity of Pain:
4
Behavioral Assessment of Pain Intensity:
Nonverbal Cues of Pain:

Moaning

Quality of Pain:

Dull

Relieving Factors:

Rest

Aggravating Factors:

Psychosocial Assessment

Coughing

Created By: M Flores, SNPC 02/10/2016 | 18:11

Psychosocial Assessment
No assessment required at this time
Safety Assessment

Created By: M Flores, SNPC 02/10/2016 | 18:13

Orientation
Oriented to time, person, place
Fall Risk
20
Bracelet Check
Hospital ID bracelet
Morse Fall Scale
History of Falling
No=0
Secondary Diagnosis
No=0
Ambulatory Aid
None/Bedrest/Nurse Assist=0
IV or IV Access
Yes=20
Gait
Normal/Bedrest/Wheelchair=0
Mental Status
Oriented to Own Ability=0
Total Fall Risk Score

Risk Score:

20

Fall Risk Score and Preventative Measures Implemented
Fall Risk Level:

Low Risk

Fall Risk Measures:

Implement Low Risk Fall Prevention
Interventions:All admitted patients, orient to surroundings, patient and family education about risk, toileting program, bed in low position, evaluate medication response, personal items in reach, night light as appropriate, nonskid footware, decrease room clutter.

Special Precautions/Isolation Assessment

Created By: M Flores, SNPC 02/10/2016 | 18:13

Special Precautions/Isolation
No assessment required at this time
IVs
1. Right Median Vein (Forearm)

Created By: M Flores, SNPC 02/10/2016 | 18:16
IV Status:

Active
Infusion Pump in Use

Type of IV
Access:

Peripheral

Catheter Type:

Over-the-needle

Catheter Size:

20-gauge

Skin
Assessment:

Insertion site clean and dry Dressing Care:

Dressing clean and dry

Patency:

Intermittent line flushed per hospital protocol
Patent; flushes easily

Patient
Response:

No complaints at this time Vital Signs
Chart Time Temperature Respirations Pulse
Blood Pressure Oxygenation Notes
(F)
(Resp/min)
(Beats/min) (mmHg)

Entry By

02/10/2016 97.3
18:17
Site: Oral

M
Flores,
SNPC

Intake/Output
Intake

20

77
Site:
Radial

137/74
Site: Left arm
Position: Lying

Saturation:
95%
Site: Digital probe, finger
Amount: 2.5
L/min
Delivery
Method:
Nasal cannula Chart Time

Type

Description

Amount

02/10/2016

Oral Intake

PO fluids

Notes

360 mL

Entry By
M Flores,

18:18

SNPC

Output

Chart Time

Type

Description

Amount

02/10/2016
18:18

Volume

Urine void

Notes

700 mL

Entry By
M Flores,
SNPC

Height/Weight
Chart Time

Weight

Inches/cm)

255 lbs / 116 kgs
Adm
Bed scale

02/10/2016 18:19

Height (Feet

(Pounds/Kgs)

Notes

Entry By

6' / 183 cm

M Flores, SNPC

Blood Glucose

Chart Time

Glucose
Reading

Nursing
Actions

Time since last meal

Notes

Entry By

02/10/2016
18:20

344 mg/dL

Gave insulin per order

More than 6 hours M Flores,
SNPC

02/10/2016
18:20

336 mg/dL

Gave insulin per order

Less than 1 hour M Flores,
SNPC

Pharmacy
Amiodarone Tablet - (Cordarone, Pacerone)

Order Type:
Order Start Date:
Order Stop Date:
Route for Administration:
Medication Dose:
Medication Form:
Frequency of
Administration:

Routine
02/10/2016 07:00
02/16/2016 23:59
Oral
100 mg
Tablet
Daily

Azithromycin Tablet - (Zithromax, Zithromax Z-pak)

Order Type:
Order Start Date:
Order Stop Date:
Route for Administration:
Medication Dose:
Medication Form:

Created By: M Flores, SNPC
02/10/2016 | 07:00

Routine
02/10/2016 07:00
02/16/2016 23:59
Oral
250 mg
Tablet

Created By: M Flores, SNPC
02/10/2016 | 07:00

Frequency of

Daily

Administration:
Budesonide Nebulizer Suspension - (Pulmicort Respules)

Created By: M Flores, SNPC
02/10/2016 | 07:00

Order Type:

Routine

Order Start Date:

02/10/2016 07:00

Order Stop Date:

02/16/2016 23:59

Route for Administration:
Medication Dose:

Inhaled
0.5 mg

Medication Form:

Inhalation Suspension

Frequency of

Daily

Administration:
Diltiazem Tablet - (Cardizem)

Created By: M Flores, SNPC
02/10/2016 | 07:00

Order Type:
Order Start Date:
Order Stop Date:
Route for Administration:
Medication Dose:
Medication Form:
Frequency of
Administration:

Routine
02/10/2016 07:00
02/16/2016 23:59
Oral
120 mg
Tablet
3 Times/Day

Finasteride Tablet (BPH) - (Proscar)

Order Type:
Order Start Date:
Order Stop Date:
Route for Administration:
Medication Dose:
Medication Form:
Frequency of
Administration:

Routine
02/10/2016 07:00
02/16/2016 23:59
Oral
5 mg
Tablet
Daily

Albuterol/Ipratropium 3mg-0.5mg/3mL Nebulizer Solution (DuoNeb)
Order Type:
Order Start Date:
Order Stop Date:
Route for Administration:
Medication Dose:
Special Instructions:
Medication Form:
Frequency of
Administration:

Created By: M Flores, SNPC
02/10/2016 | 07:00

Created By: M Flores, SNPC
02/10/2016 | 07:00

Routine
02/10/2016 07:00
02/16/2016 23:59
Inhaled Nebulizer
2 ml
PRN dosing for bronchospasm.
Inhalation Solution
4 Times/Day

Pantoprazole Delayed Release Tablet - (Protonix)

Created By: M Flores, SNPC
02/10/2016 | 07:00

Order Type:

Routine

Order Start Date:

02/10/2016 07:00

Order Stop Date:

02/16/2016 23:59

Route for Administration:

Oral

Medication Dose:
Medication Form:

40 mg
Tablet DR

Frequency of

Daily

Administration:
PredniSONE Tablet

Created By: M Flores, SNPC
02/10/2016 | 07:00

Order Type:

Routine

Order Start Date:

02/10/2016 07:00

Order Stop Date:

02/16/2016 23:59

Route for Administration:

Oral

Medication Dose:
Special Instructions:
Medication Form:
Frequency of
Administration:

50 mg
Alternate nostril used with each dose.
Tablet
Daily

Simvastatin Tablet - (Zocor)

Order Type:
Order Start Date:
Order Stop Date:
Route for Administration:
Medication Dose:
Medication Form:
Frequency of
Administration:

Routine
02/10/2016 07:00
02/16/2016 23:59
Oral
20 mg
Tablet
Daily in the Evening

Warfarin Injection - (Coumadin IV)

Order Type:
Order Start Date:
Order Stop Date:
Route for Administration:
Medication Dose:
Special Instructions:
Medication Form:
Frequency of
Administration:

Created By: M Flores, SNPC
02/10/2016 | 07:00

Created By: M Flores, SNPC
02/10/2016 | 07:00

Custom Time
02/10/2016 07:00
02/16/2016 23:59
IV
2.5 mg
Dose adjusted to INR goal
Injection Solution
Once

Laboratory
Comprehensive Metabolic Panel
Category:
Order Priority:
Order Frequency:
Order Start Date:

Panels
Routine
One Time
02/10/2016 06:00

Created By: M Flores, SNPC 02/10/2016 | 06:00

Specimen:

Venous blood

Results:
Comprehensive Metabolic Panel
Test Name

Result Value

Reference Value

g/dL

Albumin

Unit

3.5 to 5 g/dL or
35 to 50 g/L (SI units) Bilirubin

mg/dL

Bilirubin (Indirect)

mg/dL

0.2 to 0.8 mg/dL

Bilirubin (Total)

mg/dL

0.3 to 1.0 mg/dL

Bilirubin (Direct LDL)

mg/dL

0.1 to 0.3 mg/dL

mg/dL

Adult: 10 to 20

Blood Urea Nitrogen

25

(BUN)

mg/dL
Elderly: May be slightly higher than those of adults Calcium (Ca)

mg/dL

Total calcium
Adult: 9.0 to 10.5
Ionized calcium
Adult: 4.5 to 5.6
Elderly: Values tend to decrease

Carbon Dioxide (CO₂)

26

mEq/L

23 to 30 mEq/L or 23 to 30 mmol/L (SI units)

Chloride (Cl)

98

mEq/L

98 to 106 mEq/L or 98 to 106 mmol/L (SI units)

0.94

mg/dL

Female: 0.5 to
1.1 mg/dL or 44 to 97 µmol/L (SI units) Male: 0.6 to 1.2 mg/dL or 53 to
106 µmol/L (SI units) Elderly:
Decrease in muscle mass may cause decreased values

units/L

Adult 30 to 120 units/L or 0.5 to
2.0 µKat/L
Elderly: Slightly higher than adults

mEq/L

3.5 to 5.0 mEq/L or 3.5 to 5.0

Creatinine

Alkaline Phosphatase
(ALP)

Potassium

4.6

mmol/L (SI units)
Protein, Total

g/dL

6.4 to 8.3 g/dl or
64 to 83 g/L (SI units) Sodium (Na)

130

mEq/L

136 to 145 mEq/L or 136 to
145 mmol/L (SI units) Aspartate

units/L

Adult: 0 to 35

Aminotransferase

units/L or 0 to

(AST) (SGOT)

0.58 µKat/L (SI units) Females: Tend to have slightly lower values than males Elderly: Values slightly higher than adult values

Blood Sugar, Fasting
(FBS)

336

mg/dL

Complete Blood Cell Count (CBC)
Category:
Order Priority:
Order Frequency:
Order Start Date:
Specimen:

Adult:
Fasting: 70 to
110 mg/dL or less than 6.1 mmol/L (Fasting is defined as no caloric intake for at least 8 hours.)
Casual: Less than or equal to
200 mg/dL (less than 11.1 mmol/l)
(Casual is defined as any time of day regardless of food intake.)
Elderly: Increase in normal range after age 50 years Created By: M Flores, SNPC 02/10/2016 | 07:00

Panels
Stat
One Time
02/10/2016 07:00
Blood

Results:
Complete Blood Cell Count (CBC)
Test Name
Red Blood Cell Count

Result Value

Unit
RBC ×

Reference Value
Male: 4.7 to 6.1

(RBC)

10⁶/µl

Female: 4.2 to
5.4
(RBC × 10⁶/µl or
RBC × 10¹²/L [SI units]) Hemoglobin (Hgb)

13.7

g/dL

Male: 14 to 18 g/dL or 8.7 to
11.2 mmol/L (SI units) Female: 12 to 16 g/dL or 7.4 to 9.9 mmol/L (SI units)
Pregnant female:
Greater than 11 g/dL Elderly: Values are slightly decreased Hematocrit (Hct)

41.7

Percent

Male: 42% to
52% or 0.42 to
0.52 volume fraction (SI units)
Female: 37% to
47% or 0.37 to
0.47 volume fraction (SI units)
Pregnant female:
Greater than 33%
Elderly: Values may be slightly decreased RBC Indices: Mean
Corpuscular Volume
(MCV)

µm³

80 to 95 µm³

RBC Indices: Mean
Corpuscular
Hemoglobin (MCH)

pg

27 to 31 pg

RBC Indices: Mean
Corpuscular
Hemoglobin
Concentration (MCHC)

g/dL
Percent
(%)

32 to 36 g/dL (or
32% to 36%)

RBC Indices: Red
Blood Cell Distribution
(RDW)

Percent
(%)

11% to 14.5%

White Blood Cell
Count (WBC)

Blood Smear

9.7

mm³

5000 to
10,000/mm³ or 5 to 10 × 109/L (SI units) Text

Normal quantity of red and white blood cells

(RBCs WBCs) and platelets
Normal size shape and color of RBCs
Normal WBC differential count
Normal size and granulation of platelets Platelet Count

372000

mm³

150,000 to
400,000/mm³ or
150 to 400 ×
10⁹/L (SI units)

Mean Platelet Volume

fL

7.4 to 10.4 fL

(MPV)
Arterial Blood Gases (Blood Gases)
Category:
Order Priority:
Order Frequency:
Order Start Date:
Specimen:

Panels
Stat
One Time
02/10/2016 07:00
Arterial blood

Digoxin Level (Digoxin)
Category:
Order Priority:
Order Frequency:
Order Start Date:
Specimen:

Created By: M Flores, SNPC 02/11/2016 | 07:00

Blood tests
Routine
One Time
02/11/2016 07:00
Venous blood

Comprehensive Metabolic Panel
Category:
Order Priority:
Order Frequency:
Order Start Date:
Specimen:

Created By: M Flores, SNPC 02/11/2016 | 06:00

Panels
Routine
One Time
02/11/2016 06:00
Venous blood

Digoxin Level (Digoxin)
Category:
Order Priority:
Order Frequency:
Order Start Date:
Specimen:

Created By: M Flores, SNPC 02/10/2016 | 07:00

Blood tests
Routine
One Time
02/10/2016 07:00
Venous blood

Comprehensive Metabolic Panel
Category:
Order Priority:
Order Frequency:
Order Start Date:
Specimen:

Created By: M Flores, SNPC 02/10/2016 | 07:00

Panels
Routine
One Time
02/12/2016 06:00
Venous blood

Created By: M Flores, SNPC 02/12/2016 | 06:00

Digoxin Level (Digoxin)
Category:
Order Priority:

Blood tests
Routine

Order Frequency:

One Time

Order Start Date:

02/12/2016 07:00

Specimen:

Created By: M Flores, SNPC 02/12/2016 | 07:00

Venous blood

Diagnostic Tests
X-Ray Examinations

Created By: M Flores, SNPC 02/10/2016 | 07:00

Diagnostic Type:

Chest w/o Contrast

Order Priority:

Stat

Transportation:
IV Required:

No Assist
No

Oxygen Required:
Order Start Date:

No
02/10/2016 07:00

Results:
Day of
Examination:

Wednesday

Report Findings:

NO acute abnormality

General Orders
Code Status
Status:
Intervention:

Created By: M Flores, SNPC 02/10/2016 | 00:00
Active
Full code

Code Status
Status:
Intervention:

Created By: M Flores, SNPC 02/10/2016 | 06:00
Active
Full code

Nutrition
Regular/General Diet
Status:
Order Start Date:
Diet Type:
Consistency:

Created By: M Flores, SNPC 02/10/2016 | 00:00

Active
02/10/2016 00:00
Regular/General Diet
Normal

Patient Card
Order
Description
Date/Time

Category

Status

Last
Discontinued Entry By
Performed By

02/10/2016 Full code
| 00:00

Code Status

Active

--

----

M Flores,
SNPC
02/10/2016
00:00

02/10/2016 Full code
| 06:00

Code Status

Active

--

----

M Flores,
SNPC

02/10/2016
06:00
02/13/2016 Nursing Intervention-

Patient

| 02:23

Teaching

Respiratory management- Active

--

----

M Flores,
SNPC
02/13/2016

Incentive spirometry

02:23

(IS)
02/10/2016 Normal
| 00:00

Regular/Gene ral Diet

Active

--

----

M Flores,
SNPC
02/10/2016
00:00

02/13/2016 Chronic obstructive
| 01:29

Care Plan

Active

--

----

M Flores,

pulmonary disease

SNPC

(COPD)-Impaired

02/13/2016

gas exchange

01:29

02/13/2016 Chronic obstructive
| 02:22 pulmonary disease
(COPD)-Impaired
gas exchange

Care Plan

Deleted

--

----

M Flores,
SNPC
02/13/2016
02:22

02/13/2016 Chronic obstructive
| 02:32 pulmonary disease
(COPD)-Activity
intolerance

Care Plan

Active

--

----

M Flores,
SNPC
02/13/2016
02:32

Patient Teaching
Category: Nursing Intervention
Sub Category: Respiratory management :

Created By: M Flores, SNPC 02/13/2016 | 02:23

Status:

Active

Teaching
Topics:

Incentive spirometry (IS)

Topics Taught: Benefits, Overview and purpose,
Overview of procedure, Symptoms to report to provider

Person(s)
Taught:

Patient

Teaching
Method(s):

Verbal Explanation and Discussion,
Demonstration, Return
Demonstration Given

Learning
Barriers:

No Barrier

Outcome:

Verbalizes Understanding, Able to
Give Return Demonstration

Charting Grading:
Charting
Grade:
Remarks:
Competencies
No competencies entered.
Remarks:

5

6

Overall Grading:
Care Plan

Pre-Clinical Manager Grade:

Grade:

Charting
Grade:

Overall Grade:

Complete

Remarks:

Please upload pdf to Canvas for grading!

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