Student Name: Emily Lopez Clinical Date: 11/7/17 Assigned Unit: CICU

Age: 75 Gender: Admission date: Resuscitation Status: Full Code

Male 11/02/2017
Admit weight: 55kg Height: 150 cm

Reason for Hospitalization:

-Cardiac Arrest
-Ischemic Cardiomyopathy
-Coronary Artery Disease
Past medical history:
-Gout
-Hyperlipidemia
Past surgical history:
-Distant history of colon resection and gallbladder surgery.
-Is scheduled to have a CABG since he has triple vessel disease.
History of present illness:
-Witnessed ventricular tachycardia: cardiac arrest.
-Right Bundle Branch Block.
-Heart Failure
Clinical Preparation Form N414

Laboratory Values: Complete the table with applicable lab values, for the
results/trend indicate if value is increased or decreased from previous result
TEST NORMAL VALUES DATE/TIME RESULT/ REASON FOR ABNORMAL VALUE AND
RECENT EFFECT OF ABNORMAL VALUE
TREND (POTENTIAL SYMPTOMS)
White blood cells 3.6-10.6 11/07/2017 8.0 Within Range
(WBC) 0533

Red blood cells (RBC) 4.50-5.20 11/07/2017 3.58 Low Low, can be because of cells being under
0533 Stress with MI, and there was an increase
of cells lysis. There is a decrease of RBC
production.
Hemoglobin (Hgb) 13.5-17.5 11/07/2017 11.3 Low Low, because there is low count of RBCs,
0533 and a decrease production of RBCs.

Hematocrit (Hct) 41.0-53.0 11/07/2017 33.6 Low Low, because the ratio of red blood cells
0533 to the rest of the plasma is low. Because
of the lysis of cells or decrease
production of RBCs.

TEST NORMAL VALUES DATE/TIME RESULT/ REASON FOR ABNORMAL VALUE AND
 RECENT EFFECT OF ABNORMAL VALUE
TREND (POTENTIAL SYMPTOMS)
Platelets 150-400 11/07/2017 153 Within Range
0533

Prothrombin time (PT) 12-15.2 secs 11/04/17 14.5 Within Range

International 1.1 or below 11/04/17 1.1 Within Range

normalized ratio (INR)

Partial thromboplastin 24-37 11/04/17 66 High High, because he is on blood thinners to

time (PTT) help decrease the possibility of blood
clots.
Sodium (Na) 137-146 11/07/2017 142 Within Range
0533

Potassium (K) 3.5-5.0 11/07/2017 3.9 Within Range

0533

Chloride (Cl) 102-111 11/07/2017 108 Within Range

0533

Glucose 65-99 11/07/2017 109 Is high by medical book standards, but in

0533 the system we wouldn’t administrate
insulin unless he was above 140. But can
be high because of his nutrition and being
on so many meds. Also he has decrease
movement so the cells haven’t the need
to uptake the glucose in the blood
system.
Hemoglobin A1C 4%-5.6% 11/03/17 4.7 Within Range

Cholesterol 11/02/17 134 Within Range

<200 mg/dL 2100

Blood Urea Nitrogen 8-20 11/07/2017 16 Within Range

(BUN) 0533

Creatinine .77-1.35 11/07/2017 0.66 Low Low, from his lower muscle mass and
0533 might have a low protein diet, he is also
aging (75).

Pre-albumin 15-36 mg Not

Recorded

Albumin 3.5-5.5 11/07/2017 3.7 Within Range

0533

Calcium (Ca) 8.4-10.4 11/07/2017 8.4 Within Range

0533
Phosphorus 2.5-4.5 mg/dL 11/07/2017 3.3 Within range
0533
TEST NORMAL VALUES DATE/TIME RESULT/ REASON FOR ABNORMAL VALUE AND
RECENT EFFECT OF ABNORMAL VALUE
TREND (POTENTIAL SYMPTOMS)
Bilirubin Total bilirubin: 0.1-1.2 11/07/2017 0.6 Within Range
mg/dL 0533

Alkaline phosphatase 44-147 IU/L 11/07/2017 57 Within Range

0533

ALT (alanine 7-56 units/liter 11/07/2017 22 Within Range

aminotransferase) 0533

AST (aspartate 10-40 units/liter 11/07/2017 22 Within Range

aminotransferase) 0533

CK 22-198 U/L Not

Recorded

CK MB 3-5% or 5-25 IU/L Not

Recorded

Troponin Lower then 0.01 ng/mL 11/04/17 26 High High, he just had a heart attack. This
value is normally high following a heart
attack and is a great indicator to confirm
heart attacks.
B-natriuretic peptide >100 pg/mL 11/02/17 293 High High, because he has heart failure. This
(BNP) 2100 lab helps indicate heart failure and helps
with diagnosis.
Other Labs

Arterial Blood Gas:

pH 7.30-7.45 11/07/2017 7.36 Within Range
0533

pC02 38-42 mmHg 11/07/2017 38.8 Within Range

0533

PaO2 75-100 mmHg 11/07/2017 100 Within Range

0533

HCO3 22-28 mEq/L 11/07/2017 22.5 Within Range

0533
Oxygen saturation 75-100 mm Hg 11/07/2017 96 Within Range
0533
Lactic Acid 0.5-1 mmol/L 11/02/17 0.5 Within Range
 2100

Allergies:
Allergies: NKDA Type of Reaction: ------

Standards of Care:
NO YES INTERVENTIONS ORDERED
DVT prophylaxis X Heparin
Stress ulcer prevention X Change positions Q 2 hours
Ventilator-associated pneumonia (VAP) X

Intake/Output:
Diet Order: NDD2 Restrictions: No Precautions: Sit at 90 Gag Reflex Intact: No, needs
(National Dysphagia Diet) thin liquids degree position in chair supervision during meals.
when eating.
Appetite (good, fair, poor): Breakfast % Lunch % Dinner %
Good 100% 75% N/a

Total Oral Fluid Intake: Total IV Fluid Intake: Total Output: 950
1281.7 N/a

Enteral Feeding: Rate: Type of enteral feeding tube:

N/a N/a N/a

Problems swallowing YES NO

Problems chewing YES NO
Dentures YES NO
Needs assistance with feeding YES NO

Intravenous Therapy:
IV Fluid: N/a Type of Solution: N/a IV rate: N/a Indication: N/a

IV Fluid: Type of Solution IV rate Indication

Peripheral Access Site Assessment YES NO

IV site and catheter gauge: IV dressing dry, no edema, redness of site X
20 gauge, right forearm.

Central Access (CVC) Site Assessment YES NO

Central line site: # of lumen: Alcohol caps present (if used) X
Right Arm 3
Indication for line: Medication Dressing dry and intact X

Elimination:
Last bowel movement: 11/7/12
Large, loose, brown.

Constipation YES NO
Diarrhea YES NO
Flatus YES NO
Incontinence-bowel YES NO
Urinary hesitancy YES NO
Urinary frequency YES NO
Burning YES NO
Incontinence-urinary YES NO
Unusual odor YES NO

Activity:
Type of activity ordered:
As tolerated with bed mobility
training, and a one person
transfer assist.
Ability to walk (gait): Shuffled Morse Falls scale score: 35
steps, able to support self for
limited amounts of time. Needs
assistance.

Use of assistive devices:

Cane YES NO
Crutches YES NO
Walker YES NO
Crutches YES NO
Prosthesis YES NO

Physical Assessment Data:

BP: Temp/Method: Pulse: Respiratory rate: SpO2:
129/90 36.2 77 16 92

Neurological:
Glasgow Coma Assessment *Describe any abnormalities in box below: 15
Eye opening response Score: 4 Spontaneously
Verbal response Score: 5 A&O
Motor response Score: 6 Obeys commands.

Pupil Assessment
 Right pupil size Size: 3mm
Left pupil size Size: 3mm
PERRLA YES: X NO:

LOC: Describe orientation Alert and Orientated X 4

Able to follow commands YES NO
Grip equal, bilateral YES NO
Sensation intact to all extremities YES NO
Speech clear YES NO
Sensory deficit (hearing, vision, taste, smell YES NO
Dizziness, vertigo YES NO
Use of assistive device (glasses, hearing aids) YES NO Specify: Uses glasses
**Additional detail required in box for abnormal findings**

Cardiovascular:
Pulses (radial, pedal) palpable, equal, strong YES NO
Normal heart tone (S1, S2), regular YES NO
Capillary refill (<3 seconds all extremities) YES NO
Extremity temperature warm to touch, YES NO
bilateral upper and lower extremities
Edema presence YES NO Specify location and degree 0-4 scale

Pacemaker YES NO Specify type (temporary, permanent)

**Additional detail required in box for abnormal findings**

Respiratory: Additional detail

Respiration pattern regular without effort YES NO
Use of accessory muscles YES NO
Productive cough YES NO
Sputum production YES NO Description of sputum:

Nonproductive cough YES NO

Lungs clear to auscultation, all fields YES NO
Use of oxygen YES NO Specify mode and flow rate of oxygen: 3 liters,
NC.

Oxygen humidification YES NO

Smoker YES NO Specify current or past hx:

Ventilation
Is patient on ventilator? YES NO
Ventilator mode N/a
FiO2 N/a
PEEP N/a
Rate N/a
Tidal volume N/a
Type of airway tube N/a
Indication N/a

Is patient requiring Bipap or YES NO Specify type:

CPAP?
FiO2 N/a
IPAP* N/a mmH20
EPAP* N/a mmH20
Rate (For Bipap ONLY) N/a
IPAP-Inspiratory positive airway pressure; EPAP-Expiratory Positive Airway Pressure

Gastrointestinal: Additional detail

Abdomen soft, nontender, all quadrants YES NO

Bowel sounds present x4 quadrants YES NO Specify: active, hypoactive, absent

Nausea YES NO
Vomiting YES NO Description:

NG tube YES NO Describe drainage color, amount,

consistency, location of tube:

Problems swallowing YES NO

Problems chewing YES NO
Dentures YES NO
Needs assistance with feeding YES NO
Stool YES NO Describe amount, color, consistency: Large,
Loose, brown in color.

Ostomy YES NO Describe type of ostomy, stoma site and

output:

Additional GI tubes YES NO Specify:

**Additional detail required in box for abnormal findings*

Urinary:
Continent, voiding without difficulty YES NO
Incontinent YES NO Interventions: Foley catheter

Foley catheter, patent, down drain, secured YES NO

to leg
Urine clear, light yellow to amber, no odor YES NO
Additional GU tubes YES NO Specify

**Additional detail required in box for abnormal findings**

His Foley catheter was inserted by the genito-urinary staff (Is that the right name for them?), they
were having a hard time with insertion. His penis did turn a purple and has been leaking blood from
his catheter since insertion. The nurse and techs have been applying gaze and keeping the area clean.
Musculoskeletal:
Normal muscle tone without weakness YES NO Does have muscle weakness
Able to transfer independently YES NO Is a one person assist transfer
Purposeful movement, all extremities YES NO
Normal skeletal alignment/structure YES NO
Altered gait YES NO Specify: Has trouble walking because of
catheter being uncomfortable.

Orthopedic device (cast, splint, brace) YES NO Specify

Fall risk YES NO Specify rationale: Has IVs, catheter and muscle
weakness.

**Additional detail required in box for abnormal findings**

Skin:
Skin dry, intact, color within patient norm YES NO
Mucous membranes moist YES NO
Evidence of skin breakdown YES NO Specify location:

Rashes or bruising YES NO Specify location:

Sutures, staples, steri-strips YES NO Specify:

Wound drainage YES NO Describe drainage:

Wound drain YES NO Specify:

Braden Score: 20

**Additional detail required in box for abnormal findings**

Psychosocial and Cultural

Marital status/children/social support: Has a very good support system. His son witnessed his heart attack
and performed CPR until EMS arrived. His daughter flew in from New Jersey, she is a radiologist and her
husband is a physician. His wife has come in to visit him during meal times.

Religious preference: Not religious preference

Occupation: Works for a car company, he inspects the car and tires.

Pain
Pain Score __2_____ out of 10 (10 being severe pain, 1 minimal pain)
Characteristics A dull ache around his chest area.

Onset Occurs with breathing and some movement. Along with the occasional cough.

Location Chest/rib area.

Duration During the time of movement, or cough. Pain fades fast.

Exacerbation With movement, deep breaths, and any applied pressure.

Radiation Radiates around the ribs, chest area.

Relief Stopping the reason for exacerbation.

Associated No other symptoms.

symptoms

Medication List: For all PRN and scheduled meds please include the following
 Trade name
 Generic name
 Mechanism of action (how does the drug work)
 Dose/route/frequency
 Indication for the drug (why is the patient receiving the medication)
 Major side effects
 Nursing implication
 Special precautions

Pathophysiology: Provide a detailed description of the patient’s disease process including

clinical signs and symptoms associated with the disease
Aspirin: Salicylates
MOA: Has an anti-inflammatory effect that can decrease fever and interferes with clotting by
keeping platelet-aggregating substances from forming.
Dose: 81 mg Tab, Chew, Daily
Indication: Used to help with thinning blood.
Major Side effect: GI bleeding, Tachycardia, pancreatitis, Hepatitis, hyperkalemia.
Nursing Implication: Watch for GI pain, ensure that its given with enough water and food to
help decrease GI pain.
Special precautions: Watch liver function labs, platelet levels and bleeding time.

Atorvastatin: Lipitor
MOA: Stops HMG-CoA reductase and helps with cholesterol biosynthesis.
Dose: 40 mg Oral tab Daily at bedtime
Major Side Effect: Insomnia, abdominal pain, musculoskeletal pain, rash, nausea, diarrhea.
Nursing implications: May increase ALT, AST and CK levels. Avoid drinking grapefruit juice.
Special Precautions: Monitor stools, and maintain balanced input and output.

Insulin Lispro: Humalog

MOA: Helps decrease blood sugar by allowing glucose into the cells.
Dose: Use the correction factor scale, subcutaneous injections.
Major Side effect: Hypoglycemia
Nursing Implications: Ensure that blood glucose is being monitored and a blood glucose test
was conducted before administrating insulin.
Special Precaution: Use the correction factor scale to use the correct dose. Watch for signs of
hypoglycemia and hyperglycemia. Check before meals.

Metoprolol tartrate: Lospresor

MOA: Unknown action but does cardiac output and depress renin secretion and peripheral
resistance.
Dose: 12.5 mg oral Tab BID
Major Side Effect: Bradycardia, dyspnea, fatigue, bronchospasms, heart failure, edema.
Nursing Implication: Watch vital signs; ensure that blood pressure and respiration rate isn’t
lower then indicated.
Special Precaution: Take with meals since it increases absorption.

Pantoprazole (Protonix): PPIs (Antiulcer drugs)

MOA: Inhibits proton pump activity by binding to hydrogen-potassium and it suppresses
gastric acid secretion.
Dose: 40 mg IV push Injectable daily at bedtime. Admin over 2 minutes (at least)
Major Side Effect: Hyperglycemia, dyspnea, nausea, vomiting, diarrhea.
Nursing Implications: Dilute with 10 ml of NS, may increase glucose and lipid levels. Also may
increase LFT result values.
Special Precautions: May increase INR and PT, so monitor patient and lab values. Educate
patient to watch for bleeding.

PRN

Heparin Flush
MOA: Is an anticoagulant, deactivates thrombin and prevents blood from clotting.
Dose: heparin flush 10 units/ml IV solution, 30 units = 3 ml IV push, injectable. As directed
PRN
Indication: To maintain line patency.
Major Side Effect: Hyperkalemia, hemorrhage, overly clotting time prolonged
Nursing Implication: Watch lab values, and liver function. Take into account which line to
draw blood from, it can ruin the line.
Special Precaution: Educate patient to watch for bleeding.

Potassium Chloride: Potassium supplements

MOA: Replaces potassium and maintains potassium levels.
Dose: 20 meq IV piggy back, injectable PRN, admin over 2 hours.
Indication: Potassium replacement protocol.
Major side effects: Respiratory paralysis, hyperkalemia, arrhythmias, heart block, cardiac
arrest.
Nursing implication: Watch for hyperkalemia, hypertension and get baseline lab values.
Special precautions: Watch for discomfort or reddening at the IV site, and tell the patient to
report any s/s of hyperkalemia.

Magnesium Oxide: Maox

MOA: Magnesium replacement.
Dose: 800 mg, oral tab, PRN
Indication: Magnesium replacement protocol.
Major side effects: Diarrhea, hypermagnesaemia
Nursing implication: Watch magnesium lab values.
Special precautions: Monitor for overdose s/s, also monitor input and output.

Sodium Chloride 0.9% (Normal saline flush range dose)

MOA: Is an electrolyte replacement to help maintain level.
Dose: 10-20 ml flush. Soln-IV as directed PRN
Indication: To maintain line patency before and after medication administration and
following blood draw or blood administration.
Major Side Effect: Pulmonary edema, heart failure, tissue necrosis at injection site.
Nursing Implication: Monitor electrolyte levels, may increase sodium levels and decrease
potassium levels.
Special Precautions: Watch for electrolyte imbalance, and make sure to scan in the flushes.
Pathophysiology: Provide a detailed description of the patient’s disease process including
clinical signs and symptoms associated with the disease

Cardiac Arrest with a right bundle branch block and V-fib: Cardiac arrest is a sudden onset of
cessation of cardiac activity, in this case it was caused by v-fib, which can have happened
because an artery became blocked. His history of past hyperlipidemia could have caused this.
This means that the ventricles, the bottom chambers of the heart twitch but doesn’t fully pump
blood. This can lead to other complications if the heart decides to clot and travel to the heart or
brain. The right bundle branch block happens when the electrical conduction is blocked and the
right ventricle doesn’t contract but the left bundle branch still works normally.

Ischemic Cardiomyopathy: Is a problem with the heart muscle, they either become thickened
or stiff and takes on a much larger appearance. This makes it harder to pump blood through the
heart and to the rest of the body. This can lead to heart failure and can be caused from a heart
attack because blood can’t reach the muscle to oxygenize them or from coronary artery
disease, because the vessels are to narrow for the blood to travel to the muscles.

Heart Failure: The heart is able to fill or eject blood and this decrease the cardiac output and
can lead to fluid building up in the lungs, heart and body. Right-sided heart failure can come
from ineffective right ventricular contractions. Left sided heart failure is caused by ineffective
ventricular contraction, which leads to pulmonary congestion and edema. Causes can be from
anemia, arrhythmias, emotional stress, atherosclerosis with myocardial infarctions and
infections.

CAD: Can be caused by increased level of low-density lipoprotein, it can irritated or damaged
the coronary vessel. These streaks can damage the protective barrier and form fatty streaks.
Then the fatty substance is covered in smooth muscle cells and can stimulate calcium
depositions. These fatty deposits narrow the vessels, making it harder for blood to move from
or to the heart or to the body. These plaques can rupture and can travel to the lungs or brain,
leading to a pulmonary embolism or stroke.
 References:

Davis's Drug Guide for Nurses 15th Edition by April Hazard Vallerand PhD RN FAAN (Author),
Cynthia A. Sanoski BS PharmD FCCP BCPS (Author)

Hinkle & Cheever: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th Edition.