Hospital Database NURS 212

Instructions: Use blue ink for day before clinical & red Ink for the clinical day. Get all of this
information on the day before clinical, then update it on the day of care.

PATIENT PROFILE
ADMISSION
INFORMATION Student Name: DC Collins
1.) Date of 2.) Patient Initials: 3.) Age: 57 3.) Growth and 4.) Sex: 5.) Admission
Care: LS (face Development Middle M (face Date:01-21-10
01-27-10 sheet) Adulthood – Gen.vs. sheet) (face sheet)
Stagnation
6.) Reason for Hospitalization (face sheet):
l. large hemothorax - syncope 7.) Medical Diagnosis: (Present diagnoses, past diagnoses;
physician’s History and Physical notes in chart; nursing
8.) Surgical Procedures: Date 01-26-10 intake assessment and Kardex)
L. sided video-assisted thoracoscopic evacuation of Past: Hypertension, Hypercholesterolemia, Depression,
hemothorax and potential decortication (surg. report seizure disorder, alcoholism (pt. states two years dry)
not yet available) Recent: Cracked ribs mid-December

• Surgical Pathophysiology: Video thoracoscopy is performed in the operating room under general anesthesia.
Patients have basic anesthetic monitoring including arterial pressure, electrocardiogram, continuous
transcutaneous oxymetry, and end-tidal carbon dioxide tension. To ensure maximal exposure, a double-lumen
endotracheal tube is used. After intubation, patients are placed in the appropriate lateral decubitus position.
Videothoracoscopic procedures are performed with trocars or ports and usually require three 1- to 2-cm
intercostal incisions. When possible, the sites of previously placed chest tube thoracostomies are used.
Paraphrased from http://ats.ctsnetjournals.org/cgi/content/full/63/2/327

• Primary Medical Dx: left side hydropneumothorax

Pathophysiology (detail on the cause of the primary medical diagnosis):

Hydropneumothorax = both Air and Pleural Effusion
Pneumothorax: These occur as a result of trauma or pre-existing pulmonary disease (eg TB, malignancy,
emphysema, histiocytosis X, interstitial fibrosis). Trauma can allow gas into the pleural space via penetration of the
visceral pleura, chest wall, diaphragm, mediastinum or esophagus. Iatrogenic pneumothorax as a result of CVP
lines, thoracentesis or mechanical ventilation is not uncommon. However, widespread emphysema is the most
common cause of secondary pneumothorax. Other causes of pneumothorax such as asthma, certain interstitial
lung diseases, lung carcinoma or abscess are less common. An uncommon cause of pneumothorax is from the
accumulation of gas produced by microorganisms in an empyema.
Pleural Effusion: Systemic arterial vessels supply both pleural surfaces. Lymphatic vessels from the parietal
pleura drain to lymph nodes along the anterior and posterior chest wall, whereas lymphatics from the visceral
surface drain to the mediastinal lymph nodes. The pleural space normally contains 0.1-0.2 mL/kg of a colorless
alkaline fluid, which has less than 1.5 g/dL of protein. The venous side drains approximately 90% of accumulated
fluid in the pleural space, whereas lymphatics absorb the other 10%. Chest-wall and diaphragmatic movements
enhance absorption of pleural fluid by the vascular and lymphatic vessels. Excessive filtration of fluid can
overwhelm these efficient absorptive mechanisms and lead to the formation of pleural effusion.
All signs and symptoms – Highlight those your patient exhibits:
Chest pain (from surgery), shortness of breath, tachycardia, tachypnea, cough (mild productive), fatigue,
cyanosis, anxiety, restlessness, decreased or absent breath sounds, tracheal shift, mediastinal shift, unequal
chest rise, hypotension, pale cool clammy skin, narrowing pulse pressure, hypoxia, hypercapnia, respiratory

1
acidosis, loss of consciousness
9.) ADVANCE DIRECTIVES (NURSE’S ADMISSION ASSESSMENTS):

Living Will: N Power of Attorney: N Do not resuscitate (DNR) order (Kardex): N

10.) LABORATORY DATA: Reason why it pertains to patient. Indicate with an “L” if low or “H” if high.
On Current
Current Value On
Test Norms Admiss Test Norms Value
Date Admission
ion Date
Glucose 65-99 125H 141H 177H Albumin 3.5-5.0 2.8L 2.8L 2.1L
13.7-
RBC 4.3-5.7 3.26L 3.55L 3.6L Hgb 12.7L 11.9L 12.0L
16.7
HCT 40-50 36L 35L 35L EOS 0-7 4 12H 2L
BUN/Creatinine
EOS ABS 0.0-0.5 0.3 0.8H 0.2L 7-24 11 39H
Ratio
11.) DIAGNOSTIC TESTS
Chest X-ray: 1/22 0951: ↑ l. pleural Chest X-ray: 1/22 1523: Bedside XR: 1/22 1912: r. tib/fib for r. leg
effusion & heart size at upper limits of AP CXR – Chest Tube Placement pain. AP & cross table. Mild diffuse
norm New l. thoracostomy tube placed. osteopenia. Mild patellofemoral
l. pleural eff. Slightly ↓ tho still osteoarthropathy.
moderate. l. lung aeration also
improved, w/persistent l. basal
consolidation. May be a tiny l.
apical pneumothorax.
CXR: 1/23/10 0910: Stable position of Chest CT: 1/23/10 1741: Chest CT CXR: 1/24/10 0834: Tube in proper
. thoracotomy tube. Redemonstration w/contrast. Follow-up post chest place. Persistent opacity l. inferior
of mod. Airspace disease at l.l.lobe. tube placement. Tube in proper half of chest obscuring l.
Mod size pleural eff, tho slightly ↓ position. l.l.lobe atelectasis & hemidiaphragm consistent w/ pleural
from last exam. No pneumothorax small l. sided pleural eff. w/ a disease. No pneumothorax. Heart not
identified. Heart size normal. displaced l. 9th rib fracture. Minimal enlarged.
atelectasis in r. lung base.
CXR: 1/25/10 0754: Tube in proper Chest CT: 1/25/10 0931: w/o CXR: 1/26/10 0755: Portable AP
place. Interval drainage of l. pleural contrast. Tube in proper place. Chest tube stable. No interval change
eff. Poor compliance of underlying Residual l. pneumothorax 26mm, to l. basilar opacity. No
lung – hydropneumothorax at l.lung slightly larger laterally, slightly pneumothorax.
base, but no increase in atelectasis. smaller anteriorly. Atelectasis
Stable patchy mild consolidation at r. appears unchanged in size. Small
lung base. Mild cardiomegaly. No r. pleural eff still present.
evidence of l. ventricular failure. Mediastinal lymph nodes present,
largest medial to main pulm.
artery. Displaced l. 9th & 10th rib
fractures identified.

CXR: 1/26/10 1028: Tube has been

repositioned. Interval decrease in l.
pleural eff. No pneumothorax
identified. Cardiomegaly unchanged.
Diffuse bilat. Interstitial and airspace
opacities noted, consistent w/pulm.
edema.

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13.) ALLERGIES/PAIN
13.) Allergies NKDA (medication 14.) When was the last pain medication given?
administration PCA Dilaudid q8min prn. Actively used.
records): D/C’d PCA Mid Shift Percocet 1300

14.) Where is the pain? 14.) How much pain is the patient in on a scale from 0-10?
l.l. chest (Nurses’ notes) 8/10 (Nurses’ notes, flow sheet)
U.R. Leg 0/10 chest, 8/10 U.R. Leg, 10/10 if standing/walking

15.) TREATMENTS
15.) Treatments (Kardex): l. chest tube What are the treatments for? Relieve hydropneumothorax
Nicotine Replacement Patch Relieve smoking withdrawal
Turn cough deep breathe Pneumonia prophylaxis
Retention Catheter to gravity Prevent urine retention
Chest tube at neg. 20 cm wall suction Drain hydropneumothorax Suction D/Cd
Incentive Spirometer qh when awake Prevent pneumonia, exercise lungs
HoB @ 60 deg. at all times Ease of breathing
16.) Support services (Kardex): ---
17.) Consultations (Kardex): PT eval and treat as appropriate
OT eval and treat as appropriate

18.) DIET/FLUIDS
Type of Diet (Kardex): Restrictions (Kardex):       Gag reflex intact     
NPO Day of Surgery (1/26) until fully awake, then clear liquids remaining day of surgery. Post-op day 1 advance
diet as tolerated to Cardiac Low Fat/Cholesterol/Salt
Appetite:      Good      Fair      Poor X Breakfast %100 of liquid Lunch% 25 Supper%---
--- Started on clr liq, advanced as above for lunch

What types of foods are included in this diet and what foods should be avoided? See Above
Low fat, cholesterol, salt foods allowed

Fluid Intake: (Oral & IV) Check Those Programs That Apply:
NPO day shift -
24 hours • Problems: Swallowing     , Chewing     , Dentures      (Nurses’ Notes)
600 mL
• Needs assistance with feeding      (Nurses’ Notes)
Tube Feedings:     
Type and Rate       • Nausea or Vomiting      (Nurses’ Notes)
(Kardex) 300 ml postop
(arrived from PACU 1310) • Overhydrated or dehydrated      (evaluate total intake and output on flow
thru day shift
sheet)

• Belching:       Other:      

• Is the patient’s intake greater than output? No • Calculate: -300

19.) INTRAVENOUS FLUIDS (IV Therapy Record)

Type and Rate: IV dressing dry: edema:       redness: Other:
D5W 10 ml/Hr Not Observed LFA, mid forearm, saline lock.
D5W 10 ml/hr – D/C’d mid LFA near wrist. Dry, no edema or redness. dry, no edema or redness
shift

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20.) ELIMINATION
Last Bowel Movement: 01/24 24-hour Urine Output: See #18 above Foley/Condom catheter: Yes
01/24 600 Urine + 550 CT drainage = 750 No
Check Those Problems that Apply:
• Bowel: constipation X diarrhea      flatus      incontinence      belching     

• Urinary:      hesitancy      frequency      burning      incontinence      odor     Other:      

21.) ACTIVITY (Kardex, flow sheet)
Ability to walk (gait): Type of activity orders: Use of assistive devices: cane, Falls-risk assessment
Not ob-served but is Amb. TID post op day walker, crutches, prosthesis: None rating: Hendrich II, Score
post op Antalgic, but 1 & OOB to chair for None = 4 – High Risk
well balanced, strong all meals. Same 1, Low Risk
No. of side rails Restraints (flow Weakness: No post Trouble sleeping (Nurses’ Notes):
required (flow sheet): sheet): op assessment Post op, unknown
None ordered 0 None None None by end of shift None
PHYSICAL ASSESSMENT DATA
22.) BP (flow sheet): 22.) TPR (flow sheet): 23.) Height: Weight:
119/90 37.6/63/18 175.3 cm 90.2 kg
97/68 96.3/78/20 --- ---
REVIEW OF SYSTEMS (Check Nurses’ Notes and shift assessments for the latest information you can get.)

24.) NEUROLOGCIAL STATUS:      

LOC: alert and oriented to person, place, time (A&O x 3), confused, etc.: Speech: Clear, Appropriate
A&O x3, drowsy post op Clear, Appropriate
A&O x3 – drowsy until mid shift when PCA D/C’d
Sensation: 4 extremities Intact x4 Pupils: PERRLA Sensory deficits for
Intact x3 Intact vision/hearing/taste/smell:---
Loss of sensation to touch in upper right leg after PERRLA – 3 mm None
standing or walking for a couple of minutes None
25.) MUSCULOSKELETAL SYSTEM:
Bones, joints, muscles (fractures, contractures, arthritis, spinal Muscle Strength: Grips equal
curvatures, etc.): Fracture l. ribs 9&10, dx of r. leg mild diffuse Strength 3/5 and equal x3
osteopenia, mild patellofemoral osteoarthropathy
Severe pain (10/10), burning, and numbness in upper right leg
upon standing or walking for more than a couple of minutes.
Motor: ROM x 4 extremities       Casts, splint, collar, brace, Walker, W/C, CPM
5/5 x4 5/5 x4 None None

26.) CARDIOVASCULAR SYSTEM:

Pulses (apical, radial, pedal) (to touch or with Capillary refill (<3s): Edema, pitting vs. nonpitting: 0
doppler): Pulses present bilat. radial & dorsalis --- (upper/lower) 0
Present and strong, apical, radial, and dorsalis <3 No edema
Jugular neck vein (distention): Heart Sounds: S1, S2, regular, irregular:      Any chest pain:
No (rate, rhythm, strength) murmur, S3, S4 S1 S2 Yes, 8/10 – r/t surgery
None S1, S2, No extra sounds 7/10 before Percocet, 1 after
Diaphoresis: No No
Nausea: No No
TED hose/plexi-pulses/compression devices: type: None None Other: --- No

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27.) RESPIRATORY SYSTEM:
Depth, rate, Use of Cyanosis: Sputum: color, Cough: productive, Breath sounds: Dim
rhythm: Depth accessory No amount: nonproductive: bilat. bases
Reg, Rate 20 muscles: --- No --- --- A few rales left side
Depth regular, No None observed Mildly productive Dim bilat. Bases,
Rate 20 rales bilat bases
Use of oxygen / Flow Rate: Oxygen Pulse oximeter: Smoking:
*1310 arrived from PACU on 4L NC. *1440 Sats in 70’s – humidification: % oxygen 40+ pack
put on mask & ↑ O2 to 6L. --- saturation years – still
*1450 Sats still ↓ing, incr. O2 to 9L – Sat ↑ to 92% Yes 92% smokes
96% on 6L maskstart of shift. ↓ to 85% off mask mid shift, 92% ---
↑ 92% using Inc.Spirom., back to 88% off Inc.Spirom.
Weaned to 4L late in shift. Off O2 by end of shift.
28.) GASTROINTESTINAL SYSTEM:
Bowel sounds x 4 quadrants: NG tube: describe
Abdominal pain, tenderness, guarding; distention,
+ on Ausc drainage:
soft, firm: Not observed – pre op pt stated no pain.
Hypoactive after liquid ---
None
breakfast, absent 1 hr later None
Ostomy: describe stoma site and stools: --- Other:---
None None
29.) SKIN AND WOUNDS:
Color, turgor, Rash, bruises: Describe wounds (size, Edges Type of wound
Temp: --- location): Chest Tubes left side approximated: drains:
WNL Color / None X2 – Not Observed Not Observed ---
temp approp. CT x2 l. side --- None
With No tenting
Characteristics of Dressings (clean, dry, Sutures, staples, steri-strips, Risk for Other: ---
drainage: --- intact): Intact other: --- decubitus ulcer
CT Drainage thin, red, CT dressings clean, assessment ---
non-purulent dry, intact --- rating: Braden
19/23 20/23
30.) EYES, EARS, NOSE, THROAT (EENT):
Eyes: redness, drainage, Ears: --- drainage:--- Nose: redness, drainage Throat: sore:---
edema, ptosis --- No drainage edema --- Not sore
No redness, drainage, No drainage or edema
edema, ptosis
PSYCHOSOCIAL AND CULTURAL ASSESSMENT
34.) Occupation
31.) Religious 32.) Marital 33.) Healthcare benefits and 35.) Emotional
None (face
preference --- status insurance None (face state Calm and
sheet): Long
(face sheet): S sheet): cooperative
Haul Trucker
Additional information to obtain from clinical units the night before clinical specific to your patient’s diagnosis:
Standardized Pressure ulcer Standardized skin Standardized Clinical Patient education
falls-risk assessment: assessment: nursing care pathways materials:
assessment: Y Y plans: : Y
Y Y Knowledge deficits:
Y --- Use of Inc. Spirom
Self care deficits:
--- ---

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Other Assessment or Treatment Information not include above:      
Doppler ordered for U.L. Leg – search for thrombi – none observed

New Medical Orders:      

D/C PCA
D/C D5W along with the PCA
D/C Tele
Wean from O2
D/C Suction

6
 Concept Map Boxes, Nursing 212

Student: DC Collins Patient LS Room: 7A701 Date: 012710

1. Include all abnormal data from Database and only from the database.
2. Include all medications and treatments.
3. Identify only problems focused on in Nursing 212.
4. Use only NANDA 2003-2004 diagnoses. Potential for problems cannot be in a box without an actual problem.
5. Knowledge deficits for different areas should be written as separate problems.
Priority: 3 Priority: 1
Problem: Acute Pain r/t Problem: Ineffective Breathing
fluid accumulation in the Pattern r/t decreased lung
pleural space and chest expansion and alveolar collapse, 2º
trauma, and r/t tissue to air and fluid in the pleural space
damage, 2º to surgical aeb dyspnea and difficulty
incision aeb verbalization of maintaining appropriate O2
discomfort saturation
-Pain level 8/10 reported -Dx of Pleural Effusion
-Medication delivered via -Pain
PCA -Diminished breath sounds at
-Chest Tubes bases
-fractured L. 9th & 10th ribs -Mild rales left side
-CXR / CT: hemothorax,
pneumothorax, with alveolar
- Mild patellofemoral collapse
osteoarthropathy -Mild consolidation at bases
-O2 in 70’s at 4L NC, Still ↓ at 6L by
mask, and 92% on 9L by mask
-Surgical Sedation
-Cyclobenzaprine -Order to TCDB
-Ketorolac -Order for Incent. Spirom.
-Hydromorphone -HoB ordered to 60 deg at all times
-APAP/Oxycodone -Smoker 40+ pack years

-Guaifenesin
-Albuterol

Priority: 4 Reason For Priority: 2

Problem: Risk for Infection Hospitalization: Left Side Problem: Ineffective Tissue
r/t surgical incision and Hydropneumothorax / Perfusion: Cardiopulmonary r/t
ineffective protection, 2º to VATS Evacuation of excessive bleeding and decreased
chest tube placement and Hemothorax and cardiac contractility aeb
VATS, and uncontrolled potential decortication uncontrolled hemothorax and Dx of
hemothorax, aeb blood labs cardiomegaly
and open pathways into the
body
-High Eosinophil count Key Assessments: -Syncope was cause of ED
-Low RBCs (only highest priority) admission
-Low Hct O2 Saturation -Glucose 141
-High Eosinophils and Abs. Breathing Pattern -Hct and RBCs Low, replaced by IV
Eosiniphils Pain Saline

7
-Low Hgb Vitals -CXR and CT show Cardio-megaly
-Foley Wound sites -BP 119/90
-Chest Tubes LOC -Low Albumin
-Temp of 37.6C Chest Tube Dressing
Most recent K+ labs -Triamterene/HCTZ
-Nitroglycerine
-Atenolol

Connected boxes (if cannot I don’t know:

draw connections) : -Retention Catheter
1:       -Nicotine Replacement Patch
2:       -Mild diffuse osteopenia
3:      
4:      
-Ondansetron and Promethazine – Relieve N / V
-Naloxone – Counter Opioids
-Al.Hydroxide/Mg Hydroxide/Simethicone - Heartburn
-Diphenhydramine - Itching
-Bisacodyl - Constipation
(From Schuster, P.M.: Concept Mapping: A Critical Thinking Approach to Care Planning, 2002, with permission

8
 Concept Map Step 4, 5, NURS 212

Student: DC Collins Patient: LS Room: 7A7-1 Date: 01-27-10

Problem No. 1: Ineffective Breathing Pattern r/t decreased lung expansion and alveolar collapse, 2º to air
and fluid in the pleural space aeb dyspnea and difficulty maintaining appropriate O2 saturation
General Goal: Effective Breathing Pattern
Behavioral Outcome Objective(s)/ Expected Outcome: (use MOSTR)
1. The patient will exhibit self care AEB demonstrating pursed-lip breathing and using the incentive
spirometer hourly on the day of care.
2. The patient will demonstrate the ability to breathe comfortably AEB absence of labored breathing and O2
saturation above 92% on the day of care.
Nursing Interventions Type of inter- Dele- Patient Responses
Include each type: (A) assessment, (T) treatment, vention gate (Evaluation)
(E) education, (D) dependent, (I) independent, (C) (A, T, E, D, I, (Y/N)
collaboration, (EOC) assess EOCs; Include C, EOC)
frequencies for each. List medication names.
1. Demonstrate pursed-lip breathing and explain T,E,I Y Patient said he understood,
benefits and tried it several times.
2. Demonstrate use of Incentive Spirometer (IC) T,E,I Y Had an IC on table, but said
and explain benefits nobody told him what it was
for. He demonstrated use.
3. Assess patient understanding of pursed-lip I, A,EOC N After education, patient
breathing and incentive spirometer, and probable demonstrated both
level of compliance proficiently with practice.
4. Assess respiratory function, including lung I,A,EOC N No labored breathing. Dim.
sounds, for labored breathing, and O2 sats sounds & rales bilat bases.
continuously if in distress; qH when O2 Sat is above 92% avg on O2, mid 80’s off
92% mask most of shift.
5. Assess Chest Tube for movement, and for I,A N CT remained in place, suction
proper drainage, proper suction, appropriate D/C’d, drainage continued
bubbling in chamber
6. Titrate O2 as ordered to increase O2 saturation T,D N *9L by mask beg. of shift
above 92% 92%.
*6L by mask early in shift
93%
*Off O2 for bathing, 85% - IC
use brought back up to 92%
*4L by mask late in shift 92%
*Off O2 by end of shift, low
90’s.
Summarize impressions of patient progress toward outcomes, whether they were met, and how the plan
should be modified: With education, he learned that he could feel better and have more energy with proper
breathing techniques and IC use. Was able to be off O2 long enough to bathe and ambulate by mid shift, and
stay off O2, including after ambulation, by end of shift.
(Note: this opportunity to see how important patient education is was as useful to me as it was to him)

9
Problem No. 2: Ineffective Tissue Perfusion: Cardiopulmonary r/t excessive bleeding and decreased
cardiac contractility aeb uncontrolled hemothorax and Dx of cardiomegaly
General Goal: Improved Tissue Perfusion
Behavioral Outcome Objective(s)/ Expected Outcome: (use MOSTR)
1. The patient will demonstrate adequate tissue perfusion AEB palpable peripheral pulses, warm and dry
skin, adequate urinary output, absence of respiratory distress, and remaining A&Ox3 on the day of care.
2. The patient will demonstrate knowledge of treatment regimen, including appropriate exercise and
medications AEB verbalization of these on the day of care.
Nursing Interventions Type of Dele- Patient Responses
Include each type: (A) assessment, (T) treatment, intervention gate (Evaluation)
(E) education, (D) dependent, (I) independent, (C) (A, T, E, D, I, (Y/N)
collaboration, (EOC) assess EOCs; C, EOC)
Include frequencies for each. List medication
names.
1. Assess pulses, cap refill, and neuro status q2H; A,I,EOC N Pulses strong, cap refill
more often if in moderate-severe distress <3
Neuro status intact
throughout shift.
2. Keep legs below level of the heart T,I Y Done throughout shift
3. Monitor skin and I&O at least twice per shift A,I Y No cyanosis, I&O
remained in balance
throughout shift
4. Assess patient knowledge about the implications A,I,EOC N Knows smoking issues.
of smoking, proper exercise on the day of care, and Didn’t know about IC use
knowledge of medications and procedures being or that movement helps
used for his treatment, before education. healing and to prevent
clots. Did know about his
current meds.
4. Educate patient about effects of smoking on E,I N Wasn’t interested.
cardiopulmonary system and offer resources on
smoking cessation
5. Educate patient about exercises appropriate for E,I N Had more energy and felt
the shift as well as medications and procedures better after use of IC, and
again after getting OOB
to bathe.
Summarize impressions of patient progress toward outcomes, whether they were met, and how the plan
should be modified: Perfusion remained good throughout shift with good pulses. Pt voided at least 3
times. Sats dropped to mid 80’s off O2 early in shift, but progressed to being off O2 in low 90’s by end of
shift. Breath sounds still remained diminished in bilat bases, and rales were heard in both bases by end
of shift, but as the day progressed and he used IC more often, he had more energy and spent more time
OOB.

10
Problem No. 3: Acute Pain r/t fluid accumulation in the pleural space and chest trauma, and r/t tissue
damage, 2º to surgical incision aeb verbalization of discomfort
General Goal: Reduce Pain
Behavioral Outcome Objective(s)/ Expected Outcome: (use MOSTR)
1. The patient will report pain intensity: 0= no pain, 1-3= mild pain, 4-6= moderate pain, 7-9= severe
pain, 10= worst pain imaginable, and set goal level at 3/10 or better, AEB verbalization of understanding
of scale and goal rating on the day of care.
2. The patient will report that pain management regimes relieve pain AEB report of pain maintained at
3/10 or less on the day of care.
Nursing Interventions Type of inter- Dele- Patient Responses
Include each type: (A) assessment, (T) treatment, vention gate (Evaluation)
(E) education, (D) dependent, (I) independent, (C) (A, T, E, D, I, (Y/N)
collaboration, (EOC) assess EOCs; C, EOC)
Include frequencies for each. List medication
names.
1. Educate patient about pain rating system E, I N Pt. understood scale
already
2. Instruct patient about importance of managing E, I N This was new to him, but
pain level, as it is easier to manage than to bring he had already been on
pain level back down PCA and using it regularly
when awake anyway.
3. Educate patient about non-pharmacological pain E, I N Expressed interest in
relief methods, including, positioning, slow deep breathing as a way to
breathing, muscle relaxation, etc.) control pain. Stated it
helped.
4. Have patient describe how unrelieved pain will be E, I N Stated he would continue
managed with slow, deep breathing,
muscle relaxation, and
repositioning himself.
5. Administer pain medication as ordered: T, D N PCA, and later Percocet,
PCA Dilauded 0.2 mg q8M (nar- reduced pain in chest to
Percocet once PCA D/C’d, once, mid shift. Shift cotic 1-2/10, though it didn’t
ended before another dose due s) Y touch the newly reported
for U.R. Leg pain
non
6. Assess pain level q2h and after meds A, I, EOC N Pain remained low to
administered non-existent for chest
area (fractured ribs /
chest tubes) as long as
meds in effect, but
nothing helped the leg
pain.
Summarize impressions of patient progress toward outcomes, whether they were met, and how the plan
should be modified: The goal was partially met. The known and expected pains in his chest due to
fractured ribs, the presence of the chest tubes, and the hydropneumothorax were well controlled by
medications, proper breathing, positioning, etc. But the newly reported leg pain remained uncontrolled
across the shift. Recorded the pain levels and symptoms. Pt. also reported these to the physician, PT,
and OT.

11
 Problem No. 4: Risk for Infection r/t surgical incision and ineffective protection, 2º to chest tube placement
and VATS, and uncontrolled hemothorax
General Goal: Absence of Infection
Behavioral Outcome Objective(s)/ Expected Outcome: (use MOSTR)
1. The patient will remain free from signs and symptoms of infection AEB by showing no undue redness,
warmth, or discharge at the surgical or chest tube sites, and core temperature < 99C on the day of care.
2. The patient will demonstrate appropriate hygienic measures such as hand washing, oral care, and
perineal care AEB verbalizing understanding of processes and willingness to perform such care on the day of
care.
Nursing Interventions Type of Dele- Patient Responses
Include each type: (A) assessment, (T) treatment, intervention gate (Evaluation)
(E) education, (D) dependent, (I) independent, (C) (A, T, E, D, I, (Y/N)
collaboration, (EOC) assess EOCs; C, EOC)
Include frequencies for each. List medication
names.
1. Assess wound sites, chest tube insertion points, A,I,EOC N Could only assess dressings
skin, and core body temperature q2H (not wounds), which remained
clean, dry, intact.
Temperature remained in the
upper 96 deg. F range across
shift.
2. Clean wounds and change dressings q2H and/or T,I Y Dressings remained in place
as allowed by orders across shift.
3. Assess lung sounds, sputum, pt. use of incentive A,I,EOC N Lung sounds did not worsen.
spirometer, skin for moisture and breakdown. No sputum observed. No
diaphor-esis. No indication of
skin breakdown and found to
be low risk.
4. Assess pt. knowledge of and use of appropriate A,I,EOC N Patient well understood
hygiene measures before and after instruction hygiene and need to perform
it well.
5. Instruct patient where knowledge is deficient E,I N Use of IC was only observed
knowledge deficiency.
6. Have patient repeat back and demonstrate these E,I Y After instruction, he used the
measures. IC hourly
Summarize impressions of patient progress toward outcomes, whether they were met, and how the plan
should be modified: Patient maintained a lack of S&S of infection across shift, reduced his risk of pneumonia
by beginning use of IC, and demonstrated thorough knowledge of need for good hygiene to prevent infection.
His eosinophil count dropped from 12 the previous day to 2 today.

(From Schuster, P.M.: Concept Mapping: A Critical Thinking Approach to Care Planning, 2002, with
permission

12
IV Medication Administration / Other Skills Form Nursing 212

student name DC Collins date 01/27/10

I. IV Medication Administration Preparation

Complete and show form to instructor before administering the medication. After clearance from your
instructor, all parenteral medications must be administered either with a staff RN or LPN or instructor.
Medication #1 Medication #2 Medication #3 Medication #4
Drug name: generic and trade if known D5W Reglan
Metocloprami
de
Is this order current? Y Y
Date: 01/26/10 1/27/10
Time: 1515 1300
Dose Safe? Y Y
Calculation correct? --- ---
Why ordered? IV Maintenance ↑ Gastric
Motility
Allergy to this drug? N N
Primary IV site location: Left Forearm LFA prox to
Patent? Y wrist
Date inserted: Not Y
Type: Observed 1/21/10
Size: Primary
Length:
Secondary IV site present? Y – SL distal
to elbow
IV access type Peripheral Peripheral
Peripheral?
Central?
PICC?
Locked?
IV fluid type: D5W D5W
IV rate: 10 mL / hr 10 mL / hr
Side/Adverse effect #1, potential ↑ Serum Glucose Drowsiness
Side/Adverse effect #2, potential Extrapyramid
al reactions
Side/Adverse effect #3, potential Restlessness
Side/Adverse effect #4 potential
Side/Adverse effect #5, potential
Side/Adverse effects, present, include
data
Should pt. receive drug? Y None
Push Medication? --- Yes
Syringe size: 3 mL
Needle size: ---
Filter needed? ---
Administration Rate in minutes: 1-2
Syringe Pump / Piggyback ---
Medication?
Tubing expired?
Tubing primed?
Administration Rate in minutes:
NS Flush Needed? ---
NS Amount: 3 mL
NS Syringe size: 10 mL

13
Heparin Flush needed? --- No
Heparin Flush Units:
Heparin Flush Syringe size:
Give medication. Procedure --- EG
Observed/Assisted by:

14
 MEDICATION RESEARCH, Nursing 212

Instructions: Complete this form for all medications on assigned patient including PRN, all IV solutions and additives.
Bring a drug reference to clinical. For TPN, list each major component on a separate line, with additional data listed
separately. Reactions may be transposed to cards or reused from a file.

Student: DC Collins Patient Name: LS Room: 7A7-01 Date: 01/27/09

ALLERGIES: REACTION(S): May reuse this information for
subsequent patients by copying and pasting it in.
Medication name Dose Time Expected effects What should you What was the Major side effects
(trade/generic) safe? due on this patient check before assessment (most common)
Drug dose, route & this giving this med right before
frequency shift on this patient? and after the
medication?
APAP/Oxycodone Y PRN Pain relief Pain, type, loc, 8/10 U.R. Leg CNS: confusion,
325/5 mg tab intensity 8/10 U.L. sedation
1-2 tab PO Q4H PRN Chest GI: Constipation
(Percocet) 8/10 U.R. Leg
1/10 ½ hr
Chest
Al. Hydroxide / Mg. Y PRN Heartburn Existence of       Constipation
Hydroxide / Simeth-icone gastric pain
Suspension
30 ml PO Daily PRN
Albuterol SVN Y 0900 Improve Lung sounds, Dim bilat CNS: Nervousness,
2.5 mg/3 ml soln 1300 breathing pulse, BP bases, rales restlessness, tremor
Q4H bilat bases, CV: Chest pain,
before and palpitations
after

Albuterol SVN Y PRN Relieve SoB Lung sounds,       CNS: Nervousness,
2.5 mg/3 ml soln pulse, BP restlessness, tremor
PRN CV: Chest pain,
palpitations
Atenolol Y 0900 Manage BP, ECG, Pulse BP checked q CNS: fatigue, weakness
50 mg tab HTN for baseline 2H GU: erectile dysfunction
2 tabs PO Daily
(Tenormin)
Bisacodyl EC Y 0900 Treat Abd. Dist., bowel No dist., Abdominal cramps,
5 mg tab Constipation sounds hypoactive Nausea
1 tab PO BID

Cyclobenzaprine Y 0900 Relieve cramping Pain, muscle       CNS: Dizziness,

10 mg tab stiffness, ROM drowsiness
1 tab PO BID PRN EENT: dry mouth

Diphenhydramine Y PRN Relieve itching Itching       CNS: drowsiness

50 mg/1 mL IV inj GI: anorexia, dry mouth
25 – 50 mg /
0.5 – 1 ml IV Q$H PRN
Guaifenesin ER Y PRN Expectorant Lung sounds,       CNS: dizziness,
600 mg tab freq and type of headache
1 tab PO BID PRN cough, type of GI: N / V, diarrhea,
secretions stomach pain

15
 Derm: Rash, urticaria
Triamterene / HCTZ Y 0900 Prevent K+ loss / BP K+ levels WNL Hyperkalemia
37.5/25 mg tab Antihyper-tensive Latest K+ levels No edema /
1 tab PO Daily Peripheral Hypokalemia
edema at least
1/day
Hydromorphone Y PRN Relieve pain BP, pulse, CNS: confusion,
1 mg / 1 mL IV inj Resps, bowel sedation
1-2 mg IV IntQ1H PRN function, pain CV: hypotension
type, loc, GI: constipation
intensity, cough,
lung sounds
Hydromorphone Y PRN Relieve Pain BP, pulse, Dim bilat CNS: confusion,
1 mg/1ml PCA inj 30 ml Resps, bowel bases, rales sedation
0.2-0.3 mg IV IntQ8M function, pain bilat bases, CV: hypotension
type, loc, before and GI: constipation
intensity, cough, after
lung sounds
Ketorolac Y PRN Relieve Pain Pain type, loc, CNS: drowsiness
30 mg / 1mL inj intensity Misc: anaphylaxis
15 mg, 0.5 mL IV Q6H

Naloxone Y PRN Counter Opioid Resp rate, Hypersensitivity if opioid

0.4 mg/ml inj rhythm, depth use > 1 week
0.1 mg, 0.25 mL IV PRN Pulse, ECG, BP,
if RR =< 8 LOC
Nicotine Y PRN Prevent / HR, current HR 78 CNS: Headache,
21 mg/24 hr patch Manage patch site for No reactions insomnia
1 patch/24 hours Nicotine reactions before CV: tachycardia
Withdrawal replacing in new Derm: burning at patch
site site, erythema, pruritis
Nitroglycerin Y PRN Prophylaxis for BP, pulse, ECG CNS: dizziness,
0.4 mg tab #25 btl angina pectoris / headache
0.4 mg, 1 eA, Sublingual Adjunct CV: hypotension,
Daily – may repeat q5M treatment of CHF tachycardia
x3 providing SBP over 90
and call physician
Ondasteron Y PRN Relieve N / V, abd. Dist., CNS: headache
4 mg/2mL inj N/V bowel sounds GI: constipation,
4 mg/2mL IV Q8H PRN diarrhea

Promethazine Y PRN Relieve BP, Pulse, RR Confusion,

25 mg/1mL inj N/V disorientation, sedation
12.5-25 mg, 0.5 – 1mL IV
Q4H
Famotidine (Pepcid) Y 0900 Relieve --- --- Confusion
20 mg / 10 mL Heartburn
10 mL IV daily

Metoclopramide Y 1300 Incr. gastric N / V, abd. Dist, No N / V, Drowsiness,

20 mg / 2 mL motility bowel sounds bowel sounds extrapyramidal
2 ml IV daily absent reactions,
restlessness
Heparin Y 1300 Thrombus S&S of BP WNL, no Anemia,
5000 U / 1 mL prophylaxis bleeding, bruising, thrombocytopenia
1 mL q8H bruising, blood in CT
hematuria, BP drainage but
not
elsewhere

16
IV Maintenance Y Cont                        
Solution
Dextrose 5% in water
500 mL IV
Continuous

17
 Medical Surgical Report (written or verbal), Nursing 212
Student: DC Collins Date: 01-27-10
Complete and communicate to the instructor before the end of shift.
Patient: LS Room: 7A7 Patient Room

Diagnosis/Surgery: HD POD Diagnosis/Surgery: HD POD

L. Hydropneumothorax 6 1

Oncoming Report Summary: Oncoming Report Summary:

Age 57 male. Dr. Luber. L. CT x2 High temp
evening shift. Tylenol brought it back down. 9L
by mask overnight as O2 ↓ to mid 80s. Liq. diet
through breakfast, adv. to normal diet as tol. No
BM. Foley D/C’d. PCA 0.2 q8M

Assessment Summary: Assessment Summary:

Neuro: A&O x3. Drowsiness ↓ after PCA D/C’d Neuro:
Resp: 93% 4L mask. No dyspnea. RR 20 even Resp:
Dim. Sounds / Rales bilat. bases CV:
CV: S1 S2 No extra sounds, pulses strong bilat GI:
radial / dorsalis GU:
GI: No BM since 1/24. BT hypo x4 after liq. Skin:
bkfst, absent thereafter. Other:
GU: Voiding. 300 in 400 out.
Skin: Clr/Tmp approp.
Other: Act: up ad lib. Walks w/assist
Pain: 1/10 chest, 8/10 newly rep. URLeg pain
w/burning sensation & numb to touch.

Medical Interventions: Medical Interventions:

*Doppler ordered for leg pain. No thrombus
observed
*Wean off O2
*D/C Tele
*D/C PCA and D5W
*D/C Suction

MD Service, Assessment and Plan: MD Service, Assessment and Plan:

Plan to discharge 1/29

MD Service, Assessment and Plan: MD Service, Assessment and Plan:

Interdisciplinary Team Assessment and Plan: Interdisciplinary Team Assessment and Plan
PT: arrived when pt amb. the quad.
Encouraged more of same.

18
Interdisciplinary Team Assessment and Plan: Interdisciplinary Team Assessment and Plan
OT assured that stay with sister after discharge
arranged. OT found pt capable of self care.

Nursing Team Plan: Nursing Team Plan:

Encourage movement and ambulation 2x shift
Remind to use IC and purse-lipped breathing.
Observe for S&S of infection
Observe O2 q2h now that he is off O2.
Monitor pain, burning, sensation in URLeg

End of Shift Report: End of Shift Report:

*M. Age 57. *In for Hydropneumo.
*Hx of ETOH. *40+ pack years
*Full Code *A&O x3
*CTubes x2 left side. Slow drainage
*CV: HRR, good pulses
*Pulm: Dim sounds & rales bilat bases. Last O2
92% on RA
*GI/Diet: Regular *GU: Voiding
*Skin: Color/Temp appropriate
*Meds: Percocet, Albuterol, Famotidine,
Reglan, Heparin, Atenolol, Bisacodyl,
Triamterene/HCTZ, Nic Patch, Reglan
Mobility: Up ad lib, full ROM, rearranged his
own furniture. Encourage longer amb around
quad.
Mood: Excellent, joking.
*Pain: Controlled for chest 0-1/10. URLeg 8-
10/10, + burning and numbness to touch, upon
standing/walking for several minutes. Doppler
found no thrombus. Awaiting further orders.

19
 Second and Third Patient Step 4, 5: Mini-Map, Nursing
212
Complete this form for each second and third patient during the clinical day. Indicate the problem using the priority
number from the concept map. Show to instructor during the day. Use the map boxes to quickly organize data.
Student: DC Collins Patient: CF Room: ED Date: 02/03/2010
General Expected Outcomes on the day of care: Problem
1. The patient will report pain intensity: 0= no pain, 1-3= mild pain, 4-6= moderate Priority #’s
pain, 7-9= severe pain, 10= worst pain imaginable, and set goal level at 3/10 or
better, aeb verbalization of understanding of scale and goal rating by end of first 1
rounding after arrival.
2. The patient will report that pain management regimes relieve pain AEB report of 1
pain maintained at 3/10 or less by the end of shift.
3. The patient will exhibit reduced dizziness aeb report of reduced dizziness and 2
steadier gait on day of care
4. The patient will remain free from injury aeb no falls or other movement related 2
injury to self by end of shift
5. The patient will exhibit knowledge of symptoms of infection of which to be aware 3
aeb verbalizing those symptoms, including increase / spread of pain, fever or chills,
excessive sweating, nausea.
6. The patient will remain free from additional signs and symptoms of infection 3
(other than abd. pain and dizziness) aeb core temp <99F, LOC intact, no
diaphoresis, and no nausea by end of shift
General Nursing Interventions:
1. Explain pain scale (as above) to patient and elicit verbal understanding of the 1
scale from the patient upon admission to ED. (E, I – No delegation)
2. Assess pain level, type, and location immediately upon arrival and q30M (A, I, 1
EOC – No delegation)
3. Provide pain medication as ordered, prn (T, D – No delegation (narcotic)) 1
4. Assess level of dizziness – more or less than upon admission – more or less 2
upon laying down / sitting upright – more or less upon movement, immediately upon
admission and q30M. (A, I, EOC) – No delegation)
5. Use two side rails to prevent accidental fall from bed, escort pt to bathroom or for 2
any necessary ambulation (possibly with wheelchair) prn throughout shift. (T, I – can
be delegated
6. Provide call light and verify patient’s understanding that she should inform us if 2
she needs anything, to ensure compliance with bed rest, upon admission and with
each rounding q30M – (T, I, can be delegated)
7. Start IV NS Wide Open as per standing order 3
8. Assess for S&S of infection (as above #5), core temp, and LOC upon arrival and 3
q30M (A, I, EOC – no delegation)
9. Educate patient about symptoms (as above #5) immediately upon arrival 3

10. Assess labs as they become available and keep physician updated ASAP
EOCs not met (indicate # from above):
1: Pain was reduced shortly after each admin of 2 mg Morphine to 5/10, but quickly
raised back up to 7/10 (within 30 mins of report of 5/10)
2: Pt was less dizzy when sitting upright than standing, laying down than sitting
upright, and when HoB was 45 deg rather than flat. Dizziness reduced, but not
eliminated
3: No additional pain or S&S of infection *except* spread of lower R. abd. pain
spread to lower R. abd.

20
How will you modify plan? I wouldn’t. Keep pt hydrated, in bed as much as possible, assess
vitals, LOC and S&S of infection often.

Priority: 1 Priority: 2
Problem: Acute Pain r/t Problem: Impaired
undiagnosed lower back Physical Mobility with
pain aeb pt report and Risk for Injury r/t
guarding dizziness aeb pt report
and impaired gait
-Pt reports pain 7/10 in -Wheelchair to bed
R. lower back -Pt states reduced
-Guarding of lower back dizziness when laying
and abdomen down, but still exists
-Pain radiated to R.
lower abd. during shift
-Physician suspects
possible appendicitis -Zofran
-Morphine

-Morphine

Priority: 3 Reason for Priority:      

Problem: Risk for Hospitalization: Problem:      
Infection r/t lower back Dizziness – Lower Back
pain and dizziness Pain
-Physician reports Key Assessments:
suspicion of appendicitis (only highest priority)
-Vitals
-Heart Rhythm
-Orthostatic BP
-Meds recently taken
- Lungs / O2 Sat / Resps
-Rocephin -Perfusion
-NS Wide Open

I don’t know:      

     
     
     
     
     
     
(From Schuster, P.M.: Concept Mapping: A Critical Thinking Approach to Care Planning, 2002, with permission

21
 ED
Name: DC Collins Date: 02/03/2010 Score:       /10
Complete this form as your clinical day proceeds. Turn into your instructor at the end of the shift.
Please fill the data for your day of clinical that you did or someone else did. For IVT, complete only the information
that is available to the IVT team.
Most Interesting Patient Sickest Patient Another patient
Rm Last name ED Rm Last name CF Rm Last name CB
Reason Here: 85 y.o. F sent by Reason Here: 59 y.o. F, Dizziness, Reason Here: 27 y.o. F, Syncope
nursing home for vomiting x1 R. lower back pain and SoB, 30 wks pregnant, c/o
intermittent tightening stomach
muscles
Labs: Labs: Labs:
Stool, for C-diff, results not back Awaiting labs from Allenmore UA

Abnormals and reason:

Abnormals and reason: Abnormals and reason: UA – Urine hazy
UA 3+ Blood Glucose 118 H
2+ Leukocytes Pot 3.4 Low
Total Protein 6.1 L
Albumin 3.2 L
RBC 3.63 L
Hct 3.2 L
Suspected Low Iron, inadequate
nutrition, and not enough rest.
Other tests today: Other tests today: Other tests today:
Abd. C/T – results not back Abd. CT with contrast – awaiting Venous Doppler RLE LLE – no DVT
results seen
Abd CT with contrast, awaiting
results
Abnormal physical assessment and Abnormal physical assessment and Abnormal physical assessment and
times: times: times:

Attempted straight cath and foley – IV diff. to start. Former IVDA (more Pain in L. lower back radiated during
third nurse successful on several than 10 years ago. stay to bilat.
attempts.
BP 115/84 upon arrival. Dropped to HR: 116 initial assessment, 108 after
Severe rash, bright red, both mid Morphine
buttocks, reaching up inner thighs 80’s/mid 50’s after 2 mg Morphine –
and to mons pubis. next dose held

Severe diarrhea, very liquid, green BP 100/70 until 2 mg Morphine

and tarry, q5 minutes or less, and given, dropped to mid 80’s/mid 50’s
upon abd. contractions related to again. Next dose held.
pain.
Repeat of the above once more.
Stool draining out of Foley
D/C’d IV in R. FA after CT – Site
swollen, red, warm, painful to touch

Pt less dizzy upon laying down, but

still dizzy
Lung sounds: Clear Bilat
Lung sounds: Clear bilat
Heart Sounds: S1, S2, no extra
Lung sounds: Clear bilat Heart Sounds: S1, S2, no extra sounds
sounds
Heart Sounds: S1, S2 no extra
sounds
Comfort level: Comfort level: Abd. and lower back Comfort level: Pain 4/10,

22
 pain 7/10 pre-Morphine, 5/10 30 contractions pt believes are Braxton-
Severe pain when rash touched, for mins later. Continuous pattern Hicks.
cleaning after diarrhea or attempts to across shift.
insert cath, for example. Could not Pain started in Lower R back, and
state a number on a scale. spread to bilat lower back.

time med due: time med due:

time med due: IV Morphine inj 2 mg, q30M prn IV Morphine inj 2 mg, q 30 M x3 prn
Imodium ASAP, once Zofran - once IV Rocephin inj 1gm, ASAP, once
IV Zofran inj 8 mg, ASAP, once
EKG: EKG: EKG:
N/A Normal sinus rhythm Normal sinus

Pulse ox O2 pulse ox O2 pulse ox O2

Unable to take – hands too cold to 95%, 94%, 96% on RA 100, 100, 100, on RA
register
IV site: size solution IV site: size solution IV site: size solution
rate rate rate
R. Hand, 22Gauge, NS, Wide Open L. Hand, 22 Gauge, NS, Wide Open R. hand, 20 Gauge, NS, Wide Open
R.FA, 20 Gauge, NS, Wide Open for
CT, D/C’d after CT.
Vs: T: 97.6, P: 84, RR: 24, BP: Vs: T: 98.0, P: 55, RR: 24, BP: Vs: T: 99.2, P: 116 (before
109/67 96/45 Morphine, 108 30 mins later), RR: 20
(before Morphine, 16 30 mins later),
BP: 109/75,

Drains: amount Drains: amount Drains: amount

None None None

I/O analysis: I/O analysis: I/O analysis: ---

Too soon for analysis – IV NS wide Too soon for analysis, also NPO
open after scant return from Foley

Physicians (service, time rounded, Physicians (service, time rounded, Physicians (service, time rounded,
impressions and plan): impressions and plan): impressions and plan):

Suspect fistula between Suspect appendicitis Probable UTI

colon/rectum and urinary tract.

Other medical team members Other medical team members Other medical team members
(service, time rounded, impressions (service, time rounded, impressions (service, time rounded, impressions
and plan): and plan): and plan):

N/A N/A OB: FHR 135, moderate variability,

10 Accels, Zero Decels, positive fetal
movement, Acc 150 bpm x30
seconds, pt. denies bleeding or
rupture, no signs of B-H contractions
Goals for the patient today /time Goals for the patient today Goals for the patient today
needed
Reduce Pain Reduce Syncope / Improve breathing
Reduce / stop diarrhea and vomiting Reduce effect of dizziness Reduce chance of PE

Improve Rash
RN activities to achieve those goals RN activities to achieve those goals RN activities to achieve those goals

IV Start Encourage slow, deep breathing Patient laying down

IV Rocephin Admin IV Morphine Reduce Anxiety
Collect stool sample D/C infiltrated IV Suggest OB Consult

23
Urinary Cath and collect UA sample Pt. positioning Assess LE edema / for Homan’s Sign
Send for abd. CT Maintain NPO status until diagnosis Maintain LE below heart level
Keep perineal area clean Fall prevention Monitor Vitals q30M
Provide perineal moisture barrier Maintain hydration
Hold Morphine when hypotensive

Expected Time to DC/Transfer: Expected Time to DC/Transfer: Expected Time to DC/Transfer:

Needs before DC/Transfer: Needs before DC/Transfer: Needs before DC/Transfer:

Unknown – diagnosis still to be Unknown – diagnosis still to be Unknown – no timeline established

established. established. by physician

24