Student: Brett Fisher Date: 9/24

Santa Fe College
ASN Nursing Process 4/Bridge Nursing Process 2
Acute Care Nursing Clinical Assignment

Initials: DM Age: 78 Gender: M Allergies: Cipro Admit Date: 8/30

Admit Dx: Bladder Cancer
Main Reason for Hospitalization: Cystoprostectomy with illeal conduit diversion.
Pertinent Past Medical History: Hypertension, Congestive Heart Failure, Arterial Fib, Coronary Artery
Disease, MI (SVT) 9/9, DVT left arm
Brief Summary of Hospital Course: DM was admitted to the hospital on 8/30 to have a radical
cystoprostectomy, pelvic lymphadenectomy, loop colostomy, and illeal conduit urinary diversion
performed. a 78-year-old Caucasian gentleman with past medical history significant for coronary artery
disease, congestive heart failure, status post ICD placement, history of arrhythmia/A-Fib who was initially
admitted to Urology for total cystoprostatectomy secondary to prostate and bladder cancer. The patient's
surgery was performed on 08/30/2010. The surgery itself was unremarkable, however, shortly post
surgery the patient developed several complications. The patient post procedure was started on TPN
through a PICC line and he did develop a DVT in the left subclavian vein. He also had episodes of SVT
and atrial fibrillation for which cardiologist was consulted on 09/08/2010. On September 10 it was noted
that his troponin was elevated. The patient was diagnosed with acute MI for which he was transferred to
ICU. While on ICU, the patient was started on heparin continuous infusion. Shortly after he developed
hematoma on the rectus sheath complicated with wound dehiscence and evisceration which required a
second surgical intervention and repair as well as placement of a subcutaneous wound VAC dressing. The
patient returned to the floor on September 14th.

Surgical Procedure (date and explanation):

8/30/10 – Radical cystoprostectomy, Pelvic lymphadenectomy, loop colostomy, and ileal conduit urinary
diversion.
9/10/10 – Complex repair of facial dehiscence, placement of wound VAC.

Pathophysiology (of primary problem): See Attached

Clinical Manifestations (from text, star client’s manifestations):
Gross painless hematuria*
Bladder irritability with dysuria*
Frequency
Urgency
Urinary Incontinence*
Urinary Retention*
Source: (Lewis, Heitkemper, & Dirksen, 2004)    

Treatment (from text, star client’s treatment):

Segmental Cystectomy
Radical Cystectomy*
Radiation*
Intravesical Chemotherapy
Source: (Lewis, Heitkemper, & Dirksen, 2004)  

Complications (of diagnosis and surgical procedure if applicable; list from text, star any client
experienced):
Anemia*
Swelling of the ureters (hydronephrosis)
Urethral stricture*
Source: (Lewis, Heitkemper, & Dirksen, 2004)    

Radiologic Studies and Diagnostic Tests (include date of each test and results):
9/7 CT Pelvis/Abdomen
1. Large amount of intraperitoneal free air anterior to liver which is more than expected postoperatively. No
definitive source for the free air is identified, although an association with gastric tube is possible. There is a
partially closed anterior abdominal wall incision with intact underlying fascia.
2. Solitary right kidney with partially occluding clot in the proximal right ureter surrounding the ureteral
stent. There is no evidence of a leak on the current study.

Discuss the following variables as they impact this hospitalization and discharge planning:
Psychological: This patient is moderately anxious about his hospital stay and the new treatments that he is
dealing with (new medications, new colostomy, new illeoconduit, new VAC dressing and machine). Patient
stated he ”doesn’t even know what his medications are anymore because they’ve changed them so much”.
Spiritual: DM attends a church in his home-town and is fairly involved in the community of that church.
He builds furniture for the church and enjoys attending the weekly worship gatherings on Sunday. Other
than his faith and religion, DM says he finds his strength in family. This is whom he relies on when he
cannot bear things on his own.

Sociocultural: Patient is a 78-year-old gentleman from Rockledge, Florida who lives by himself since his
wife passed away. He is retired from carpentry after a 55-year career. DM has family that lives close to his
home. They are very involved in his life and have visited him frequently since his admission to the hospital.
His son calls frequently on the phone and is also involved in the care of this client.

Developmental: DM falls into the stage of ego integrity versus despair. Client has begun to accept and
approve of his own unique life. DM was a carpenter for 55 years before retiring and is very proud of
what he accomplished in his life. He has passed down wisdom to his children and remains very
close to them. Although DM has had mild depression during his hospital stay, it it more related to
his current medical situation than feelings of dispair about his life.

Priorities for Care and Teaching:

1. Monitor for infection due to surgical incisions and PICC, PIV site
2. Teach about colostomy and ileal conduit. What to expect, how to properly care, and proper diet.
3. Management of co-morbidities such as CHF, Hyperlipidemia, CAD, A-Fib, Hypertension.

Minimum of 5 Pertinent Nursing Diagnoses (Use three part format: problem, etiology, and symptoms as
appropriate), prioritize according to client needs and/or Maslow’s Hierarchy:
1. Impaired Skin Integrity r/t surgery and imbalanced nutritional state AMB destruction of epidermis
and dermis skin layers at surgical sites (Midline, Stomas, G-Tube site, Retention sutures), report of
pain at Midline and G-tube site, and poor nutritional intake due to nausea.
2. Risk for Infection r/t tissue destruction.
3. Imbalanced nutrition: less than body requirements r/t inability to digest food AMB lack of food
interest and decrease bowel motility.
4. Ineffective Tissue Perfusion (Gastrointestinal) r/t interruption of blood flow AMB nausea, inability
to keep down fluids.
5. Anxiety r/t change in health status AMB distressed, worried affect.

Self-evaluation of clinical performance:

Areas of Strength: I think that my areas of strength are patient and family interaction, and my improving
organizational skills.
Areas for Improvement: The areas that I need to improve in are managing my I and Os, continuing to
improve my assessment skills, knowledge of medications, and nursing skills.
IV Infusions and Continuous IV Medications (Please list medications, dose and show calculation for
ml/hr for each med along with nursing implications):
TPN
HAL 2000 at 84/hour
Lipids 400 at 33/hour
Laboratory Tests indicate If ↑ or ↓ next to value (Explain abnormal results)
Analysis NI Values Date: 9/23Date: 9/22Date: Interpretation

CBC RBC 4.5-5.9 3.07 L 2.98 L Surgery, Dehisince of wound

Hgb 13.0-16.5 8.7 L 8.5 L Surgery, Dehisince of wound

Hct 39.0-49.0 26.3 L 25.5 L Surgery, Dehisince of wound

Platelets 150-450 392 424

WBC 4.0-10.0 10.90 Healing process

Differential Bonds

Lymphocytes

Monocytes

Eosinophils

Basophils

ANC

Coags PT

INR

Ptt

Electrolytes Na 136-145 142 138

K 3.3-5.1 3.9 3.9

Ch 0.80-1.20 1.21 1.24

CO2 22-30 29 30

Decrease blood flow to the

BUN 6-20 40 44 kidneys

Creatinine 0.8-1.2 1.21 1.24

Glucose 65-99 99 101

Mg 1.5-2.8 2.1 2.1

PO4 2.7-4.5 3.0 3.1

Ca 8.0-10.6 7.9 7.9

Alk Phos

LFTs Bili total

Bili direct

AST
 Albumin 3.5-5 2.5 Poor nutritional intake

Cardiac CK 30-170 32 30

CK-MB <5.1 3.2 3.1

Trop <0.03 0.03 0.04 MI

Lipids Cholesterol

HDL

LDL

ABGs PH

PaO2

PaCO2

HCO3

SaO2

FiO2

UA Spec Gravity

PH

Protein

Glucose

Ketones

RBC

WBC
Meds Information:

Allergies List: Cipro

a. Trade
b. Generic names a. action of meds Common side Special nursing
c. Classification b. Why client receives effects to observe implications
d. Dosage meds for
e. Route
f. a.
1) Frequency
Cordarone 1) 1) corneal 1)
b. amiodarone a. Prolongs action potential microdeposits, anorexia, Monitor ECG during
c. Antiarhythic class 3 and refractory period. Inhibits constipation, nausea, initiation of oral
d. 200 mg adrenergic stimulation. Slows vomiting, bradycardia, therapy.
e. PO the sinus rate, increases PR hypothyroidism, ataxia Assess for signs of
f. BID and QT intervals, and pulmonary toxicity
decreases peripheral vascular 2) Headache, Peripheral
2) a. Norvasc resistance (vasodilation) Edema 2)
b. amlodipine
Monitor blood
c. Calcium channel b. Suppression of arrhythmias 3)diarrhea, nausea, pressure and
blockers insomnia, suicidal pulse before
d. 5 mg thoughts therapy.
e. PO 2.
f. Once Daily a. Inhibits the transport of 4. hypotension, Monitor intake and
calcium into myocardial dizziness output ratios and
3) a. Lexapro and vascular smooth daily weight.
b. Escitalopram muscle cells, resulting in Assess for signs
c. Antidepressant inhibition of excitation- of CHF
d. 10 mg contraction coupling and
e. PO subsequent contraction 3)
f. Once Daily
b. Management of Monitor mood
4) a. Prinivil Hypertension changes and level of
b. licinipril anxiety during
c. Ace Inhibitor 3. therapy
d. 20 mg
a. Selectively inhibits the Assess for serotonin
e. PO
reuptake of serotonin in syndrome
f. Once Daily
the CNS 4)
b. Management of Monitor blood
Depression pressure and pulse
frequently during
4. initial dosage
adjustment and
a. Angiotensin-converting periodically during
enzyme (ACE) inhibitors therapy.
block the conversion of
angiotensin I to the Monitor weight and
vasoconstrictor angiotensin assess patient
routinely for
II.
resolution of fluid
a. Trade
b. Generic names a. action of meds Common side
c. Classification b. Why client receives effects to observe Special nursing
d. Dosage meds for implications
e. Route
f. Frequency 5. 5. dizziness, fatigue, 5. Monitor blood
5) a. Coreg a. Blocks stimulation of weakness, diarrhea, pressure and pulse
b. Carvedilol beta1(myocardial) and beta2 erectile dysfunction, frequently during
c. Beta Blocker (pulmonary, vascular, and hyperglycemia dose adjustment
d. 10 mg uterine)-adrenergic receptor period and
e. PO sites 6. bleeding, anemia periodically during
f. BID b. Decreased heart rate and therapy
blood pressure in 7. hyperglycemia, Monitor intake and
6) a. Levenox management of Hypertension dehydratio, output ratios and
b. Enoxaparin and CHF. hypochloremia, daily weight.
c. anticoagulants hypokalemia,
d. 80 mg 6. hypomagnesemia, 6.
e. SC a.Potentiates the inhibitory hyponatremia, Assess for signs of
f. Once per day effect of antithrombin on hypovolemia, metabolic bleeding and
factor Xa and thrombin alkalosis. hemorrhage
7. a. Lasix b.Prevention of DVT and PE, (bleeding gums;
b. furosemide Management of A-Fib nosebleed; unusual
c. loop diuretic bruising; black, tarry
d. 40 mg 7. stools; hematuria;
e. PO a. Inhibits the reabsorption of fall in hematocrit or
f. Once per day sodium and chloride from the blood pressure;
loop of Henle and distal renal guaiac-positive
tubule stools); bleeding
Increases renal excretion of from surgical site.
water, sodium, chloride, Notify health care
magnesium, potassium, and professional if these
calcium occur

b. Management of 7. Assess fluid

hypertension status
Monitor blood
pressure and pulse
before and during
administration.
Monitor electrolytes,
renal and hepatic
function
 NURSING PROCESS RECORDING
ASSESSMENT
DATA (Subjective and Objective) NURSING DIAGNOSIS
Impaired Skin Integrity r/t surgery and imbalanced nutritional state AMB destruction
Subjective Data of epidermis and dermis skin layers at surgical sites (Midline, Stomas, G-Tube site,
- Reports of pain (7/10) at the midline incision site Retention sutures), report of pain at Midline and G-tube site, and poor nutritional
and the G-Tube site intake due to nausea.
- Reports of nausea after intake of fluids

Objective Data
- Midline incision with wound VAC
- Retention sutures
- Stoma for ileal conduit on RUQ abdomen
- Stoma for colostomy on LUQ of abdomen
- G-tube site
- Albumin level 2.5
 PLAN
CLIENT GOAL NURSING ORDERS RATIONALE
Assessment: 1. Early Regulation of delayed healing or developing complications
Client will display timely 1. Inspect incision regularly, noting may prevent a more serious situation. Incisions may heal more
healing of wounds until full characteristics and integrity. slowly in clients with co morbidity (COPD, malnutrition,
recovery and will begin to 2. Assess amounts and characteristics of hematoma formation)
demonstrate behaviors and drainage. 2. Decreasing drainage suggests evolution of healing process,
techniques to promote 3. Assess clients knowledge of dressings and whereas continued drainage or presence of bloody or odoriferous
healing and prevent care that will need to be performed. exudate suggests complications, which may include hemorrhage,
complication by 9/26. infection, and fistula formation.
3.

Strengthen Lines of Defense: 1. These actions will assist the body’s natural process of repair and
1. Keep the wound areas clean/dry, carefully protects wound from mechanical injury and contamination.
dress wounds and support incision. Use aseptic Prevents accumulation of fluid that may cause excoriation.
techniques. 2. These actions will protect the wound and the surrounding tissues.
2. Use appropriate barrier dressings, wound They reduce potential for skin trauma or abrasions and provides
coverings, drainage appliances, wound vac, additional protection for delicate skin and tissues.
and skin protective agents for open 3. This action enhances stimulation of peripheral circulation, aids in
draining/wounds and stomas. preventing venous stasis to reduce risk of thrombus formation and
3. Assist client with ambulation. Encourage enhances circulation and return of normal bowel function.
patient to ambulate as soon as possible.

Teaching/Referral
1. Consult with wound/stoma specialist for 1. These specialist can assist with developing a plan of care for
assistance with complications or assistance problematic wounds.
with care and teaching 2. This action promotes independence in care and reduces risk of
2. Demonstrate care of stoma, dressings and complications, such as infection.
drains in preparation for future discharge. 3. This action will prevent obstruction and further complications, as
3. Teach the proper diet for a stoma and wound well as enhance proper wound healing.
healing (small frequent meals, low fibers, soft
foods, lots of liquids, high protein)
 IMPLEMENTATION EVALUATION/CLIENT GOALS
NURSING ACTIONS Met, Partially Met or Not Met
1. On 9/22 student nurse and clinical instructor inspected and Goal Met. Client is displaying proper wound healing as evidence by
assessed clients midline incision during wound VAC decrease drainage and wound bed pink and granulating. Client also
dressing change. Student nurse also inspected both right expressed understanding of proper wound care.
and left upper quadrant stomas and retention sutures.
2. On 9/23 student nurse assessed and documented output of
wound VAC dressing, noting the decrease in production
over the two days of clinicals.
3. On 9/23 student nurse spoke to client and assessed
knowledge of the care of his incisions, dressings, and
stomas. Client stated that he does not know much and feels
overwhelmed by it all. He stated that he knows he will need
a home heath nurse but eventually wants to be able to
perform self-care for his stomas.
4. On 9/22 student nurses and clinical instructor performed
wound VAC dressing change using sterile technique on
DM to maintain clean/dry wound bed.
5. On 9/22 morning nurse performed stoma care for DM and
demonstrated how to change stoma bags and wafer.
6. On 9/22 student nurse encouraged DM to ambulate and
offered to assist him. DM stated he has already gone for
multiple walks but agreed to move from lying in the bed to
sitting in the chair.
7. Student nurse and nurse will consult wound care/ stoma
care specialist if assistance is needed.
8. On 9/23 student nurse demonstrated technique of caring
and emptying for colostomy and ileostomy bags. Student
nurse also emphasized importance of not touching wounds,
PICC line without proper aseptic technique.
9. On 9/23 student nurse instructed client on proper foods to
eat to enhance healing including foods high in protein,
vitamin A and C.
 References

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse's pocket guide.

Diagnoses, interventions, and rationales (11th ed.). Philadelphia, PA: F.A.

Davis Company.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2009). Nursing Care Plans (8th

ed.). Philadelphia, PA: F.A. Davis Company.

Lewis, S. M, Heitkemper, M. M., & Dirksen, S.R. (2004). Medical surgical

nursing.

assessment and management of clinical problems. St Louis, MO: Mosby.

 ASN Nursing Process 4/BR 2
Evaluation of Clinical Written Work

Evaluate each statement as an “S” for satisfactory and a “U” for unsatisfactory.

EVALUATION EVALUATION/COM
CRITERIA BY STUDENT MENTS BY
FACULTY
- Initials, age, gender completed
- Allergies identified
- Admission date, admitting diagnosis, main reason for hospitalization
(from client’s perspective, if possible) completed
- Pertinent PMH completed
- Hospital course summarized clearly and concisely from admission until
day of clinical
- Surgical procedures performed during this hospitalization identified. 5
Pathophysiology of primary problem
- Pathophysiology of primary medical diagnosis explained (selection
verified with clinical instructor). Do Not Use Dictionary
- Textbook (or other reputable source) clinical manifestations relating to
pathophysiology identified
- clinical manifestations
- treatment options
- complications of diagnosis and surgical procedure
- clinical manifestations, treatment, and complications that this client has
experienced starred 20
Radiologic studies and Diagnostic Tests
- date of each, normal values and results included 1
Variables impacting hospitalization and discharge planning
- Findings of assessment of each variable as they pertain to this client
discussed
- psychological
- sociocultural
- spiritual
- developmental (use Erikson’s stages) 5
Priorities for care and teaching
- most important issues where your energies will be focused are
identified 3
Pertinent Nursing Diagnosis
- Five nursing diagnoses listed
- Three part format of each diagnosis written out (Problem, etiology,
A.M.B.) 10

IV Infusions and Continuous IV Medications

- Medications continuously infusing identified
- IV rate needed for delivering ordered dose calculated
- Nursing implications discussed 2
 Laboratory Tests
- All laboratory tests listed
- For lab tests listed in table, results for 3 days shown
- normal values listed
- interpretation of these results mean at least attempted (NOTE:
“anemia” is just a word to describe low hct; you need to explain
why you think this person is anemic)
- Other pertinent lab tests not previously discussed on second page
of form listed, along with date and results 10
Med Information
- Source is cited
- Allergies are listed
- Trade name, generic name, classification, dosage, route and
frequency are included
- The reason the client is receiving the med and action for each med
are identified
- Common side effects to observe for are included
- Special nursing implications are listed 5

NURSING PROCESS RECORDING

Assessment-Data (Subjective and Objective)
- Data that supports your nursing dx is properly classified under
these headings:
SUBJECTIVE DATA
OBJECTIVE DATA
ADDITIONAL DATA
- Data includes cues (no inferences)
- Data reflects a complete assessment of the client for the nursing
diagnosis 5
Nursing Diagnosis
- Is appropriate for this client
- Is properly stated (Actual-used P r/t A.M.B. format; Risk
for-used P r/t format) using the NANDA list
- Reflects a situation which the nurse can order interventions to
treat or prevent 5
Client Goal
- Is a client goal
- Is realistic and attainable
- Is measurable
- Is properly stated (Includes subject, action verb, performance
criteria and target time; special condition is optional)
- Does not interfere with other client therapies
- Considers client’s level of growth and development, and
individuality
- Has a realistic time frame for achievement 5
Nursing Orders
- Are properly classified under these headings:
ASSESSMENT
DECREASE STRESSORS AND/OR STRENGTHEN
LINESOF DEFENSE
TEACHING/COUNSELING AND/OR REFERRAL
- Concise and includes: an action verb, a descriptive phrase-how,
what, where to perform the action, and a time frame-when, how
often, how long).
- Clearly stated so other personnel can carry out the orders without
question or confusion
- Appropriate to the nursing diagnosis and client
- Consistent with the medical plan for care
- Adequate to achieve the client goal
- Are numbered consecutively 10

Implementation-Nursing Actions
- Corresponded with each nursing order
- Addressed whether each order was carried out and the client’s
response
- Designates who gave the care (e.g., student nurse, team leader)
- Are numbered consecutively with the nursing orders 5
Evaluation/Client Goal
- Evaluative statement includes whether the goal was met, partially
met or not met using criteria stated in the client goal statement
- Evaluative statement includes the client’s behavior which
indicates the goal was met, partially met or not met: Date &
Time
- Includes a Reassessment statement 4
Appearance 5

Indicate if the written work is “S” Satisfactory or “U”

Unsatisfactory
Evaluation completed by:
Student and Faculty signature