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University Of Pennsylvania

School of Nursing

N240/N270 Junior Level Clinical Preparation Guide

Student’s name: Marcella Hill Date: 11/12/12 Unit: Founders 14

Patient’s Name: B.C. Age: 71y Language spoken: English

*Health literacy and numeracy: *Hearing, vision and dentition:

*(Ice Cream Test):

Advanced directive: Yes No X Present in chart: Yes No X Diet and mode of nutrition:Regular Diet

Isolation: Yes No X Type: N/A Origin: N/A

*Pre-hospital functional status: She is able to walk and get out of bed without any assistance.

And is able to take care of herself fairly well. She does have a problem with physical exertion.Usually when she exerts physical activity she experiences shortness of breath and chest pains.

Activity restrictions: None

Admission date: 11/11/12 Readmission?

Discharge plans and destination: She is planned to be discharged at home where she will

continue on the same drug regimen before. However, she is scheduled to receive a lung biopsy of the tissue to see the exact cause of her abnormal chest X-ray which will hopefully eliminate thechest pain she is experiencing.

Actual and expected transitions in care:

*Complete TRAQ tool

*Completed MED tool

Current diagnoses and conditions:

Pulmonary HTN, CHF, Pulmonary modules, possibly progressive sarcoidosis, COPD, DMII, and

CAD.

Chief complaint: She was brought in for severe chest pain. She has been experiencing chest pain

since July of 2012. She experiences substernal chest pain. The substernal chest pain she was

experiencing in July was soon to be discovered to be caused by non-obstructive CAD. However



for this visit she experienced substernal chest pain that traveled to her left arm and neck, which

worsened with exertion. The chest pain got worse when she was coughing or experiencing

palpation and is usually associated with nausea. She started to experience worsening DOE andothropnea. She also gained ten pounds and and started to get edema on her lower extremities. An

EKG and chest X-ray was performed. The EKF was normal for her past medical history of CAD

and CHF. However, her chest scan was abnormal and was found to have calcified granulomasthat were concerning for sarcoidosis. When the she is discharged the Doctor wants a lung biopsy

to see if the patient has sarcoidosis and if this is the cause of her new extreme chest pain.

Relevant History: Include relevant data regarding previous illnesses, hospitalizations,

medications taken at home.

Past Medical History (PMH): Pt. has heart failure, ischemic cardiomyopathy, Bv/icd, DMII,HTN, CAD, and pulmonary nodules.

Past Surgical History (PSH): CABG, bv/icd placement, total abdomhysterectomy, removal of

gall bladder

Significant hospital events:

• 11/11/12 She was admitted to the hospital with acute and chronic worsening of chest pain. An

EKG and chest pain was also performed.

Cultural preferences: Religion:

Ethnicity:

Social: N/A

Relationship status: Single Family caregiver:

Insurance: Yes X No Living situation:

Smoker: Yes X No if yes PPY: ETOH: Yes No if yes type:

Pertinent family history:

Home medications: Amlodipine besylate 10 mg, 1 tab oral daily

Aspirin 81 mg, 1 tab oral daily

Atorvastatin calcium (lipitor) 40 mg tab, 1 tab oral dailyCarvedilol 6.25 mg, 1 tab daily

Esomeprazole magnesium (Nexium) 40 mg, 20 mg oral daily

Fexofenadine 180 mg, 1 tab dailyGlipizide 5 mg, 1 tab daily

Lisinoprin 15 mg, 1 tab daily

Nitroglycerin 0.4 mg subl, 1 tablet every 5 min, for a most of 3 tabs in 15 mins for chest painPromethazine-codeine 6.25-10 mg 15 mL every 6 hours



Allergies: Perocet, oxycodone including previous falls: N/A

Height: 160.00 cm Weight: 77.11 kg

Vital Signs/Ranges:T: 98.2

RR: 26

BP: 158/103SO2: 93 on RA

HR: 89

Hospital medication list and rationale: (Please use additional paper if needed to list ALL

medications prescribed for patient

Order: Heparin Injection

Use/Rationale: To prevent clotting

Side Effects: Bleeding, thrombocytopeniaDosage Range: 5000 units SQ every 8 hours

Therapeutic/Safe Dose: Yes X NoRenal Impairment: Yes X No Liver Impairment: Yes X No

Pertinent Lab Values: Platelet, APTT

Peak/Trough: 2-4 hrs Nursing interventions: Look for active bleeding and bruising.

Mechanism of Action: Increases formation of antithrombin III- thrombin complex and

deactivates thrombin.

Classification: Anticoagulant

Order: Insulin Aspart Use/Rationale: The patient's glucose is high because of the increase strength on her body.Side Effects: Blurred vision, dry mouth

Dosage Range: Depends on what her blood sugar is, 1-6 units.

Therapeutic/Safe Dose: Yes X NoRenal Impairment: Yes No X Liver Impairment: Yes No X

Pertinent Lab Values: Glucose

Peak/Trough: 1-3 hrs

Nursing interventions: Monitor glucose level before administering medication, check vital signs,and rashes.

Mechanism of Action: Increase glucose transport across muscle and fat cell membranes.

Classification: Insulin

Order: Lansoprazole

Use/Rationale: Used for gastric refluxSide Effects: Abdominal pain and constipation

Dosage Range: 10 mg oral 2 times per day

Therapeutic/Safe Dose: Yes No

Renal Impairment: Yes No X Liver Impairment: Yes No X



Pertinent Lab Values: None

Peak/Trough: Unknown

Nursing interventions: Monitor for symptoms of low magnesium (abnormal HR, muscle spasms)Mechanism of Action: Inhibit proton pump activity by binding to hydrogen-potassium adenosine

Classification: Proton Pump Inhibitor

Order: Amlodipine Use/Rationale: Used for patient's HTN.

Side Effects: Peripheral Edema, headacheDosage Range: 10 mg oral daily

Therapeutic/Safe Dose: Yes X No

Renal Impairment: Yes No X Liver Impairment: Yes X No

Pertinent Lab Values: AST, ALT, BUN, CreatininePeak/Trough:

Nursing interventions: Monitor for vital signs, especially BP

Mechanism of Action: Inhibits calcium ion influx into vascular smooth muscle and myocardium

Classification: Calcium Channel Blocker

Order: LansoprazoleUse/Rationale: Used for patient's HTN

Side Effects: Diarrhea, insomnia

Dosage Range: 40 mg every night at bedtimeTherapeutic/Safe Dose: Yes X No

Renal Impairment: Yes X No Liver Impairment: Yes X No

Pertinent Lab Values:

Peak/Trough: Nursing interventions: Monitor vital signs especially BP

Mechanism of Action: Inhibits HMG-CoA reductase

Classification: Statin

Order: Carvedilol

Use/Rationale: Used for patient's HTN.Side Effects: dizziness, fatigue

Dosage Range: 6.25 mg oral every 12 hours


Renal Impairment: Yes X No Liver Impairment: Yes X NoPertinent Lab Values:

Peak/Trough:

Nursing interventions: Monitor vital signs especially HR and BP before administeringmedication.

Mechanism of Action: Selectively antagonizes alpha and non-selectively beta blockers

Classification: Beta Blocker

Order: Fexofenadine Use/Rationale: Relieve patient's allergic reactions

Side Effects: Cough, pain



Dosage Range: 180 mg oral daily


Renal Impairment: Yes X No Liver Impairment: Yes No XPertinent Lab Values:

Peak/Trough:

Nursing interventions: Monitor VS, pain, irritatiable symptoms like sore throat and itchy skin.Mechanism of Action: Selectively antagonizes peripheral histamine H1 receptors

Classification: Antihistamine 2nd generation

Order: Furosemide Use/Rationale: Used for patient's CHF

Side Effects: weakness, muscle cramps

Dosage Range: 40 mg oral dailyTherapeutic/Safe Dose: Yes X No

Renal Impairment: Yes X No Liver Impairment: Yes X No

Pertinent Lab Values: ALT, AST, Creatinine, BUN

Peak/Trough: Nursing interventions: Monitor VS, weight, I/O.

Mechanism of Action: Inhibits loop of Henle and proximal and distal convoluted tubule, andsodium and chloride resorption.

Classification: Loop diuretic

Order: Lisinopril Use/Rationale: Used patient's HTN

Side Effects: Hypotension, headache

Dosage Range: 5 mg oral dailyTherapeutic/Safe Dose: Yes X No

Renal Impairment: Yes X No Liver Impairment: Yes No X

Pertinent Lab Values: BUN, CreatininePeak/Trough:

Nursing interventions: Monitor for VS and mental status in older adults

Mechanism of Action: Inhibits angiotensin converting enzymeClassification: ACE Inhibitor

Order: Albuterol Use/Rationale: Used for patient's dyspneaSide Effects: Cough, bad taste

Dosage Range: 0.5 mL Nebulization every 4 hours

Therapeutic/Safe Dose: Yes X NoRenal Impairment: Yes No X Liver Impairment: Yes No X

Pertinent Lab Values:

Peak/Trough: Nursing interventions: Monitor for VS especially SpO2.

Mechanism of Action: Relaxes airway smooth muscles

Classification: Beta-2 agonist



Order: Ipratropium Use/Rationale: Used for patient's dyspnea

Side Effects: Nausea, dry mouthDosage Range: 2.5 mL nebulization every 4 hours


Renal Impairment: Yes X No Liver Impairment: Yes X NoPertinent Lab Values:

Peak/Trough:

Nursing interventions: Monitor VS, especially RR and SpO2Mechanism of Action: Antagonizes acetycholine receptors producing bronchodilation

Classification: Anticholinergic



Data Imaging/Labs

11/12/12

Sodium 139

Potassium 4.4

Chloride 106CO2 Content 22

Glucose 159 H

BUN 21 H

Creatinine, Serum 1.94 H

Calcium 8.9

Lactic Acid

WBC 5.9

Hemoglobin 12.8

Hematocrit 38

MCV 90MCH 30

MCHC 33

Platelet Count 208

RDW 15.6 H

Neutrophils 71.6

Absolute Neut. Count 4.25

Absolute Lymph Count 0.66 L

Absolute Mono Count 0.81

Absolute EOS Count 0.19

Absolute Baso Count 0.03Lymph 11.2 L

Monocytes 13.7 H

Eosinophil 3.1

Basophils 0.4

APTT

RBC 4.29

ALT

AST

Bilirubin

• Disease: Sarcoidosis



• Definition: Disease where inflammation occurs in lymph nodes, liver, eye, skin, or other

tissues. In this case the inflammation is in the lungs.

• Cause: Unknown, possibly genetics. In the disease granulomas (cluster of immune cells) form

in organs of the body causing inflammation. This is what was in the patient had in her chest scan,

calcified granulomas. This is why the doctors believe that her chest pain is caused by sarcoidosis.

• Signs/Symptoms: Chest pain, dry cough, SOB (These are all the symptoms that the patient

show). Other symptoms also include joint aches, fatigue, fever, rash, and dry mouth along with

other symptoms.

• Test: In physical examination the patient should usually have rales as the lung sounds, enlarged

liver, lymph glands, enlarged spleen, and rash. To diagnosis this disease a chest X-ray should be

performed, a CT scan, or a lung gallium scan.

• Treatment: Symptoms often get better without treatment. However some people have to take

immunosuppressants and corticosteroids.

• Prognosis: 30-50% cases get better without treatment, about 20% will have lung damage.

• Complications: Fungal lung infection, kidney stones, pulmonary HTN, and osteoporosis.

• Disease: Heart Failure

• Definition: Inability of heart to pump sufficiently to meet the metabolic needs of the body.

• Causes: Listed in Notebook for further info.

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