N223 Weekly Clinical Paperwork

Name: Caitlyn Wegner

Date: 10/06/20

Client’s Initials/age/gender/room number: M.J., 73 y/o M, 433

Admission problem/disease process diagnosis:

Patient had recurrent appointments with his nephrologist because he was having significant
swelling in his lower extremities from a combination of his heart and kidney problems. His
nephrologist tried a few different regimens of diuretics until one worked, it ended up being a
non-potassium sparing diuretic in a high dose. After one week, he had another appointment
where labs were drawn which showed a critically low level of potassium, 2.3 Patient instructed
to go to the emergency room immediately. Patient’s priority diagnosis was hypokalemia,
accompanied with hypochloremia, AKI, and atrial fibrillation with prolonged QT .

Pathophysiology of problem/disease process:

This patient’s hypokalemia was caused by significant over diuresis. The diuretics he had been
taking caused him to urinate excessively to get rid of third spacing fluid, however, he over
excreted and got rid of needed fluid and electrolytes causing dehydration and low levels of
potassium and chloride as well as causing a kidney injury from the kidney’s working so hard to
keep up with excreting the fluid. When potassium levels are abnormal is can cause arrhythmias,
with this patient it put him into atrial fibrillation.

What diagnostics are significant to this disease:

Basic chemistry panel for electrolyte levels, renal function panel to determine presence of kidney
injury, and EKG to show atrial fibrillation.

Signs/symptoms of problem/disease process (on admission):

Patient complained of ankle swelling that he stated has significantly decreased following use of
diuretics. Complaints of tiredness, weakness, lightheadedness, muscle cramps, soreness from
muscle cramping, constipation, and intermittent palpitations all over the past week. Patient
needed to use walker to ambulate distances due to weakness, muscle cramps and muscle
soreness. Patient also complained of a decreased appetite because of not feeling well generally
due to other symptoms.

Describe past medical history, including a description of the health condition, causes or
risk factors, treatments, and potential complications for each.
Health Description Causes/Risk Treatments Complications
Condition Factors
Obstructed Disorder Obesity, narrow Treatments Alcohol and
Sleep Apnea characterized by airway, high include regular sedative
(OSA) a cessation of blood pressure, exercise, weight medications can
(Strohl, 2020) breathing long chronic nasal loss, cessation of worsen sleep
enough to congestion, smoking, nasal apnea, use
interrupt sleep smoking, decongestants, should be
which off diabetes, asthma, allergy avoided
balances and family medications, especially
oxygen and history are all avoidance of before bed.
carbon dioxide risk factors. This sleeping on your Daytime fatigue
levels. This patient’s chronic back, and and sleepiness
usually causes emphysema most avoidance of are common
loud snoring likely contributed sedative side effects due
and snorting in to this diagnosis. medications. to repeated
the sleep. The Therapies that awakenings
cessation of may be trialed while sleeping.
breathing is include Daytime fatigue
caused by a continuous may cause
blockage in the positive airway trouble
upper airway pressure or a concentrating or
usually caused CPAP machine, falling asleep at
by a relaxation or a bilevel inappropriate
of the muscles positive airway times such as at
in the upper pressure machine work or driving.
airway. (BiPAP). Surgery This puts these
may be patients at high
considered if risk for work-
other treatments related
are not accidents. Sleep
successful. This apnea increases
patient currently the risk of
is not receiving developing
treatment for his hypertension,
OSA. arrhythmias, and
heart disease.
Mycobacterium Infection of the This infection Treatment MAC infections
Avium lungs caused by does not always involves a course can worsen
Complex the cause the host to of antibiotic already present
(MAC) mycobacterium feel unwell. medications. This lung diseases.
Infection avium complex Those who have patient is on an
-Lungs bacteria. These lung diseases or oral antibiotic,
(Tierney & bacterium are weak immune clarithromycin,
Nardell, 2018) found in water, systems are more and an inhaled
soil, and dust likely to become antibiotic,
can infect ill. amikacin sulfate
humans when liposome.
inhaled or
swallowed.
Hypertension Hypertension is Obesity, Treatments for Stress is a
(Bakris, 2019) high blood sedentary hypertension normal response
pressure. This is lifestyle, stress, include weight for every human
defined as smoking, and loss, diet and that will not
persistent high excessive changes, smokingchange,
pressure within amounts of cessation, and however coping
the arteries. alcohol or medications to mechanisms to
Blood pressure sodium in the help control deal with stress
is high once the diet can blood pressure. are important in
systolic is over contribute to maintaining
130 mmHg and development of appropriate
diastolic over hypertension. stress levels to
80 mm Hg. The patient’s prevent elevated
comorbidity of blood pressure.
chronic kidney Uncontrolled or
disease and poorly
inability to controlled
maintain fluid hypertension
and electrolyte alongside the
homeostasis may hyperlipidemia
contribute to his and heart failure
high blood puts him at a
pressure. higher risk for
another CVA or
heart attack.
Hyperlipidemia Hyperlipidemia Hyperlipidemia Treatments This patient’s
(Davidson, is defined as a may be caused by include lifestyle comorbidity of
2020) pattern of genetic factors, changes and heart failure and
elevated lifestyle, diet, or medications used hypertension
triglycerides medical to help lower alongside the
and cholesterol. comorbidities. triglycerides and hyperlipidemia
cholesterol levels. put him at
Patient is higher risk for
prescribed heart attack and
atorvastatin daily. stroke. Patient’s
Patient also tries previous stroke
to exercise daily also puts him at
by talking walks higher risk.
with his wife and
states he does his
best to follow a
healthy diet.
Chronic This disease is Cigarette Treatment This is a disease
Emphysema characterized by smoking is the includes smoking that this patient
irreversible number one cessation, relief will have to live
destruction of cause of of symptoms by with for the rest
the alveolar emphysema. This medication, and of their life. It is
 walls resulting patient has a supportive care. important that
in collapsing history of This is not a they keep up
bronchioles smoking but quit curable disease. with supportive
during exhale or 12 years ago. This patient is on treatments in
an obstruction Environmental a bronchodilator order to assist
of airflow. This factors such as to help relieve with their
typically leaves working an area symptoms such quality of life.
the alveoli polluted by as SOB caused Emphysema is
inflamed from chemical fumes, by the half of the
trapped air. dust, or heavy emphysema. disease that
smoke also causes COPD, it
increase the is likely that this
chance of patient may also
development. develop chronic
bronchitis.
Those with
emphysema are
also more prone
to developing
pneumonia.
Diastolic Heart Heart failure is Heart failure is Treatments Heart failure can
Failure defined as a commonly include dietary cause kidney
(Howlett, 2020) disorder where caused by other and lifestyle damage/failure,
the heart is cardiac diseases, changes, treating heart valve
unable to keep other body the underlying problems, heart
up with the system disorders cause, rhythm
demands of the that indirectly medication, problems,
body. This leads effect the heart, medications, and enlargement of
to congestion of untreated or in some cases the heart and
blood in the poorly treated cardioverter- liver damage.
veins and lungs, hypertension, defibrillator, This is also an
reduced blood anemia, and cardiac incurable
flow, and kidney failure. resynchronization condition so the
reduced This patient’s therapy, patient will need
oxygenation. diagnosis of mechanical to be follow
This particular chronic circulatory treatment
patient has emphysema, support, and heart regimen to
diastolic heart OSA, anemia, transplant may be prevent
failure which is CKD, and needed. worsening
a disorder of the hypertension are condition and to
ventricles. The mostly likely maximize
ventricles are related to this quality of life.
stiff and do not patient’s
completely development of
relax in between heart failure.
contractions
 which doesn’t
allow the
ventricle to
fully fill with
blood. The
ventricles still
can contract but
they are not
able to pump
out the entirety
of the blood
within them.
Cerebral This an Major risk factors CVAs typically This patient has
Vascular occurrence for CVAs include cannot be cured no deficits from
Accident within the blood atherosclerosis, or treated. TPA, a his CVA. He
(CVA)or Stroke vessels in the hyperlipidemia, reversal takes
(Chong, 2020) brain, its hypertension, medication can medications to
characterized by diabetes, and be given if within control his
an interruption smoking. Other four hours of the hypertension
of blood flow risk factors last known well and
caused by either include drug and time. This hyperlipidemia
a blockage or alcohol use, medication can to prevent
hemorrhaging. abnormal heart reverse some or reoccurrence. If
rhythm such as all side effects of another occurs,
atrial fibrillation, a stroke if given there is the
and blood in time. chance that the
clotting disorder. Otherwise patient may
This patient’s treatments suffer from
hyperlipidemia, include, blood severe deficits
hypertension, and thinners, such as paralysis
atrial fibrillation antihypertensives to right or left
most likely , medications to side of the body,
contributed to lower heart rate, slurred sleep or
this patient’s and removal or inability to talk
CVA. clot or bleeding at all, difficulty
vessel. If deficits swallowing,
are caused, impaired gait,
rehabilitation will impaired vision,
be utilized to help etc.
reach your
highest
functionality.
This patient is
being treated for
his comorbidities
of hypertension,
 hyperlipidemia,
and OSA that put
him at a higher
risk for stroke.
GERD GERD is a This is caused by Treatments Esophagitis,
(Lynch, 2019) disorder of the a malfunction include: peptic
digestive with the lower -keeping the head esophageal
system the esophageal of the bed ulcer,
stomach sphincter. Weight elevated or esophageal
contents move gain, fatty foods, staying seated stricture,
backwards into caffeinated and following meals Barrett’s
the esophagus carbonated -avoiding coffee, esophagus, and
due to a beverages, alcohol, fats, and esophageal
dysfunction in alcohol, tobacco smoking adenocarcinoma
the lower smoking, and -medications are all possible
esophageal certain drugs might include complications
sphincter. This increase the proton pump with GERD.
causes likelihood of inhibitors or H2
inflammation reflux occurring. blockers
and pain in the -do not eat within
esophagus. 3 hours of going
to bed
-if overweight,
weight loss is
advised.
Gout Gout is a This condition Treatments Gout can cause
(Edwards, condition that can be caused by include anti- joint damage
2018) affects the joints either decreased inflammatory and deformities
because of an elimination of medications, from a buildup
accumulation of uric acid by the dietary changes, of the uric acid
uric acid kidneys, high medications that crystals, this can
crystals in the consumption of prevent flare-ups cause impaired
joints that can purine-rich foods by preventing mobility, ROM,
cause severe and/or alcohol, or inflammation, and affect
joint/tissue pain production of too and medications ability to care
and much uric acid. to lower uric acid for self. Gout
inflammation. This patient most levels and can advance and
like developed dissolve already eventually cause
the disease from formed crystals. tophi which is
a decrease in Rest, formation of
kidney function immobilization, uric acid
causing and icing of the crystals in
decreased joint during flare- nodules under
elimination of the ups the skin. Tophi
uric acid. are typically not
painful but can
 flare-up during
gout attacks. In
addition, the
excess of uric
acid in the blood
stream can
cause kidney
stone formation.
Chronic Kidney Chronic kidney The most Treatment Patient’s
Disease (CKD) disease is the common causes depends on the comorbidity of
(Malkina, 2020) gradual loss of are diabetic staging and hypertension
kidney function nephropathy, underlying causes can further
leading to hypertensive of the disease. deteriorate
kidney failure. nephrosclerosis, -Control of kidney function
The decrease in and primary and underlying if not properly
kidney function secondary disorders that are controlled. This
causes an glomerulopathies contributing to patient should
inability to . CKD be following a
maintain fluid Control of -Dietary renal diet at all
and electrolyte hypertension and restriction of times to help
homeostasis. hyperglycemia protein, normalize serum
can significantly phosphate, and levels of
slow the potassium (renal sodium,
deterioration of diet) phosphate, and
the kidneys. -Restriction of potassium.
fluids These diets are
-Vitamin D not always
supplementation obtainable
-Treatment of outside of the
anemia hospital.
-Dialysis in those
with more severe
staging

This patient
controls his with
dieting and
control of
underlying
disorders.
Anemia This patient has Anemia can be Treatments Decreased
(Braunstein, anemia because caused by many include treatment oxygen
2020) of his chronic different factors of underlying perfusion,
kidney disease. depending on the renal disease and inability to
It is related to a type of anemia. erythropoietin regulate body
deficit of This patient’s and iron temperature,
 erythropoietin anemia is caused supplements. fatigue are all
because of by his CKD. Blood complications of
decreased transfusions may anemia.
kidney function. be done if the
Erythropoietin patient’s H&H
is a hormone levels reach a low
produce in the enough level. No
kidneys that current treatment
stimulates the regimen.
production of
red blood cells
within the bone
marrow. A
deficit in
erythropoietin
causes a
decrease in red
blood cell
production
therefore
causing anemia.

How does the client’s medical history impact the present problem/disease process?

The patient’s heart disease and chronic kidney disease are most impactful with the current
disease process. The heart disease and chronic kidney disease caused the third spacing of the
fluid which was why the diuretics were prescribed. The diuretics just ended up working too well
and caused electrolyte imbalances, dehydration, and an acute kidney injury.

Allergies, their drug classifications and food allergies, and client’s reaction:

No known allergies.

Client Medications/IV Solutions (Medications given during scheduled shift including PRN
medications)
Generic Name: Is this a new medication?
Potassium Chloride Yes
(pg. 1327, Shields, Fox,
& Liebrecht, 2019) Any pertinent teaching about this medication?
-Diet teaching regarding foods high in potassium
Classification: -Do not use salt substitutes unless ordered by a prescriber. Salt
Electrolyte Replacement substitutes contain high amounts of potassium.
-Do not excessively use laxatives, diarrhea can cause a
How does this medication significant loss of potassium
work? -Notify prescriber of persistent vomiting because potassium can
This medication
supplements potassium to
help raise serum potassium
levels.
Medication order:
-20 mEq in 100 mL bag, 50
mL/hr via IV, Q2h
-40 mEq controlled release,
PO, Q4
Is this a safe dose?
Dosing depends on serum
levels. Patient’s serum
potassium was critically low
and needed excessive
amounts of potassium
supplementation to reach
baseline levels.
Generic Name:
Pantoprazole
(p. 1229, Shields, Fox,
& Liebrecht, 2019)
Classification:
Gastric Proton Pump
Inhibitor
How does this medication
work?
This medication works by
suppressing gastric acid
secretion by inhibiting the
acid pump within the
parietal cells of the
be lost
-Report any signs and symptoms of hypokalemia (weakness,
fatigue, muscle cramps, palpitations, arrhythmias, etc.)
-Report any signs and symptoms of hyperkalemia (muscle
weakness, N/V, arrhythmias, etc.)
Why is this medication prescribed?
To raise serum potassium levels above a critically low level and
alleviate signs and symptoms of hypokalemia.
What pertinent pre- and post- assessments are necessary?
-Monitor for S&S of hypokalemia and/or hyperkalemia
-Strict monitoring of I&O, stop medication and report to
prescriber if oliguria occurs
-Monitor for S&S of GI ulceration
-Monitor cardiac status with cardiac assessments, EKG, and
telemetry monitoring on patient
What labs if any would need to be monitored and why?
Potassium serum need to be closely monitored to show if
medication doses need to be adjusted. Serum potassium will
also show an intoxication of potassium if it occurs. Renal
function tests should be done to determine if kidney’s can
handle excretion of medication.
List reasons why this medication may need to be held (lab,
VS, assessment findings)
Medication needs to be held if S&S of potassium intoxication is
present.
Is this a new medication?
No
Any pertinent teaching about this medication?
Contact prescriber immediately if peeling, blistering, or
loosening of the skin; skin rash, hives, or itching; swelling of
the face, tongue, or lips; difficulty breathing, or swallowing
occur.
Why is this medication prescribed?
This medication is used to decrease gastric acid thus treating
GERD and preventing acid reflux.
What pertinent pre- and post- assessments are necessary?
-GI assessments are necessary to monitor for epigastric or
abdominal pain, blood in the stool, and heart burn. This will
stomach. help assess efficacy of medication.

Medication order: What labs if any would need to be monitored and why?
20 mg tablet, PO, BID Vitamin B12 levels should be monitored with long term use
before meals because proton pump inhibitors can cause a deficiency.

Is this a safe dose? List reasons why this medication may need to be held (lab,
Yes VS, assessment findings)
This medication may cause the skin reactions Steven’s Johnson
Syndrome and Toxic Epidermal Necrolysis, if this occurs
medication needs to be held and medical help is needed
emergently. If an allergic reaction develops, medication needs
to be held.

Generic Name: Is this a new medication?

Heparin Yes
(p. 774, Shields, Fox,
& Liebrecht, 2019) Any pertinent teaching about this medication?
-Be very cautious, protect yourself from injury
Classification: -Alert prescriber if pink, red, dark brown, or cloudy urine; red
Anticoagulant or dark brown vomitus; red or black stools; bleeding gums or
oral mucosa; ecchymoses, hematoma, epistaxis, bloody sputum;
How does this medication chest pain; abdominal or lumbar pain or swelling; pelvic pain;
work? severe or continuous headache, faintness or dizziness.
This medication works - Teach proper subcutaneous injection skill if patient needs to
directly on the clotting self-administer at home after D/C.
cascade of blood -Encourage use of an electrical razor to prevent bleeding if
coagulation by enhancing platelet count is low
the inhibitory actions of -Avoid consumption of alcohol and smoking while taking this
antithrombin III thus medication
blocking the conversion of -Do not take any aspirin or OTC medications with aspirin
prothrombin to thrombin without consulting with a prescriber’s approval. Double check
and fibrinogen to fibrin. all OTC medications.

Medication order: Why is this medication prescribed?

5000 u, SQ, Q8h To prevent formation of new blood clots

Is this a safe dose? What pertinent pre- and post- assessments are necessary?
Yes -Skin assessment to monitor for any new signs of bleeding such
as hematomas
-GU assessment to monitor for bloody urine
-GI assessment to monitor for bloody stool or vomit
-Assess injection sites for reactions
-Monitor for S&S of hemorrhaging

What labs if any would need to be monitored and why?


Generic Name:
Amikacin Sulfate
(p. 68, Shields, Fox,
& Liebrecht, 2019)
Classification:
Aminoglycoside Antibiotic
How does this medication
work?
This medication is a
bactericidal that works by
inhibiting protein synthesis
in the bacteria cells.
Medication order:
590 mg, 2 puff via
inhalation, QD
Is this a safe dose?
Yes
-aPTT needs to be closely monitored to ensure the dose is
therapeutic
-Baseline coagulation tests, H&H, RBC, and platelet counts
prior to initiation and at regular intervals during therapy.
Platelet counts need to be adequate to prevent from
hemorrhaging or excessive bleeding. RBC and H&H need to be
at adequate levels for therapy and this can signal any internal
bleeding.
List reasons why this medication may need to be held (lab,
VS, assessment findings)
-Signs and symptoms of hemorrhaging or internal bleeding are
present.
-If a procedure is upcoming and it is indicated that this
medication needs to be held
Is this a new medication?
No
Any pertinent teaching about this medication?
-Teaching on proper use of an inhaler
-Report immediately any changes in hearing or unexplained
ringing/roaring noises or dizziness, and problems with balance
or coordination.
Why is this medication prescribed?
To treat MAC infection in the lungs
What pertinent pre- and post- assessments are necessary?
-Monitor for signs and symptoms of ototoxicity and any
abnormal auditory symptoms
-Monitor I&O, GU assessments to monitor for oliguria,
hematuria, and cloudy urine. Nephrotoxicity can be caused by
this medication.
-Respiratory assessments
What labs if any would need to be monitored and why?
Liver and kidney function panels because this medication can
cause hepatotoxicity and nephrotoxicity. Peak and trough levels
of amikacin need to be drawn throughout therapy to determine
proper dosing and prevent a toxicity of medication.
List reasons why this medication may need to be held (lab,
VS, assessment findings)
-S&S of an allergic reaction
-S&S of nephrotoxicity, hepatoxicity, and ototoxicity.
 -High levels of amikacin indicated on trough

Generic Name: Is this a new medication?

Clarithromycin No
(p. Shields, Fox,
& Liebrecht, 2019) Any pertinent teaching about this medication?
-Complete prescribed course of antibiotic therapy unless
Classification: discontinued by prescriber
Macrolide Antibiotic -Report any S&S of an allergic reaction
-Report loose stools or diarrhea during and after drug therapy.
How does this medication
work? Why is this medication prescribed?
This medication works by To treat the MAC infection in the lungs
binding to the ribosomal
subunit of susceptible What pertinent pre- and post- assessments are necessary?
bacterial organisms and -GI assessments, if diarrhea is present ruling out of a
blocks RNA mediated superinfection (pseudomembranous colitis) is necessary
protein synthesis.
What labs if any would need to be monitored and why?
Medication order: -Monitor peak and trough levels to determine need for dosing
500 mg tablet, PO, BID changes or toxicity
-Monitor RBC, H&H, and aPTT as clarithromycin therapy with
Is this a safe dose? an anticoagulant can cause elevated levels
Yes -Monitor renal function levels to ensure kidneys can excrete
medication

List reasons why this medication may need to be held (lab,

VS, assessment findings)
-High levels of clarithromycin levels indicated on trough
-S&S of an allergic reaction

Generic Name: Is this a new medication?

Atorvastatin No
(p. 132, Shields, Fox,
& Liebrecht, 2019) Any pertinent teaching about this medication?
-Report unexplained muscle pain, tenderness or weakness,
Classification: especially with malaise or fever; yellowing of skin or eyes;
Antilipemic stomach pain accompanied by N/V or loss of appetite; skin rash
or hives.
How does this medication -Minimize alcohol use while on this medication
work?
This medication works by Why is this medication prescribed?
inhibiting an enzyme Reduces “bad” cholesterol (LDL and total triglyceride)
essential to hepatic production and raises “good” cholesterol (HDL). Treating
production of cholesterol patient’s comorbidity of hyperlipidemia.
which increases the number
 hepatic LDL receptors and What pertinent pre- and post- assessments are necessary?
causes an increase in LDL -Assess for muscle pain, tenderness, or weakness; if present
uptake and metabolism. monitor CPK (creatine phosphokinase) levels
-Monitor for S&S of hepatoxicity
Medication order:
20 mg tablet, PO, QD What labs if any would need to be monitored and why?
Liver function panel to monitor for hepatoxicity. Lipid levels to
Is this a safe dose? determine therapeutic effect and need for dosing changes. CPK
Yes to monitor for myopathy.

List reasons why this medication may need to be held (lab,

VS, assessment findings)
-S&S of hepatoxicity
-S&S of myopathy or elevated CPK levels

How does it Nursing

Lab Normal Trends Today’s relate to your Intervention/
Range (i.e. Value patient’s disease Assessment/Follow
(Bryant & Yesterday, process? up: What do you do
Stratton) day prior) about it?
WBC 5-10,000 7.3
RBC F: 4.2-5.4 3.75 The is patient has Continue to
M: 4.7-6.1 chronic kidney monitor levels,
disease which no interventions
affects the body at this time.
to produce Levels are within
enough RBC normal limits for
because the an anemic
kidneys are not patient. Monitor
producing patient’s O2
enough saturation to
erythropoietin. ensure proper
oxygen
perfusion. If
patient becomes
symptomatic
(tachycardia,
fatigue,
weakness, pale
and clammy skin,
etc.) may need to
administer
PRBCs.
 Erythropoietin
injections are also a
possibility.
Hgb F: 12-16 11.0 Read RBC
M: 14-18
Hct F: 34-47 3.19 Read RBC
M: 42-57
Platelet 150-400 301
Na 136-145 133 143 Patient’s sodium This patient’s range
level was low due is in within normal
to dehydration limits after second
and the use of blood draw. No
diuretics. In interventions needed
addition, there at this time. Continue
were a few other monitoring
electrolyte electrolytes.
imbalances, so it
is common for
others to become
abnormal.
K 3.5-5.0 2.3, 2.3, 3.2, Patient’s Administer
2.3, 2.9, 3.0, admission supplemental
2.4, 3.3, 3.8, diagnosis was potassium as
2.3 3.9 hypokalemia. His prescribed. Continue
potassium level is monitoring levels.
critically low Assess for signs and
because of symptoms of
diuretics he was hyperkalemia. Assess
taking. for resolving
symptoms of
hypokalemia.
Abnormal potassium
levels can cause
arrhythmias, so it is
important to monitor
the patient’s heart
rhythm.
Cl 98-106 82 110 Patient’s chloride This patient’s range
level was low due is in within normal
to dehydration limits after second
and over use of blood draw. No
diuretics. In interventions needed
addition, there at this time. Continue
were a few other monitoring
electrolyte electrolytes.
imbalances, so it
 is common for
others to become
abnormal. Also
related to the
AKI.
Mg 1.3-2.1 2.2 2.53 This patient’s Continue monitoring
magnesium levels levels. Follow a diet
are high because that is low in
of his chronic magnesium to avoid
kidney disease. extra intake.
His kidneys are Hydration can help
unable to excrete kidneys excrete.
properly. The
other electrolyte
abnormalities
also could be
affecting his
levels.
Ca 9-10.5 9.8 9.9
Phos 3-4.5
BUN 10-20 152 101 This patient’s Continue to monitor
BUN & CR are levels. Treatment of
elevated because the dehydration will
the over diuresis help resolve AKI.
caused an AKI. Administration of IV
Patient’s levels at fluids as needed.
baseline are Dialysis can help
elevated because lower levels if levels
of chronic kidney become too high.
disease however
they are still
above his
baseline.
CR F: 0.5-1.1 3.71 2.53 Read BUN.
M: 0.6-1.2
GFR 16 25 Low levels of Continue to monitor
GFR indicate levels until baseline
kidney disease. is reached. Treat AKI
This patient has with fluids. Continue
CKD. The levels to monitor kidney
may be lower function.
than normal
because of AKI.
Cholesterol <200
Triglyceride F: 35-135
 M: 40-160
HDL F: >55
Cholesterol M: >45
BNP <100 751 This number is Continue to monitor
likely elevated levels. Follow
from the patient’s treatment regimen
heart failure. This for underlying causes
lab indicates that of heart failure to
the heart is not prevent worsening
pumping blood condition. Treat a-fib
the way it should. by treating
This patient hypokalemia by
being in a-fib is administering
affecting the potassium
hearts ability to supplementation.
pump normally Thorough cardiac
which also can assessments to
cause an monitor for changes.
elevation in these Continuous heart
numbers. monitoring on
telemetry while in
hospital.
CK-MB 5-25
Myoglobin <90
Troponin I <0.03 97 83 Troponin levels “”
elevated from a Treatment of AKI
combination of with fluid
the AKI/CKD, replacement to
heart failure, and prevent worsening of
tachyarrhythmias. CKD.
Lactic Acid 0.5-1
Procalcitonin <0.15
INR 0.8-1.1
aPTT 30-40
UA
(Urinalysis)
Specific 1.005- 1.020
Gravity 1.030
pH 5.0-7.0 5.5
Bilirubin Negative Negative
Blood Negative Negative
Glucose Negative Negative
Ketones Negative Negative
Leukocyte Negative Negative
Esterase
Nitrite Negative Negative
Protein Negative Negative
How does it Nursing
Lab Normal Trends Today’s relate to your Intervention/
Range (i.e. Yesterday, Value patient’s disease Assessment/Follow
(Bryant & day prior) process? up: What do you
Stratton) do about it?
ABGs
pH 7.35-7.45
paO2 80-100
paCO2 35-45
HCO3 22-26 33 30 The patient’s Continue to monitor
body is having a levels. Treatment of
hard time metabolic alkalosis
maintain its acid- is treating the
base levels underlying cause.
because of the Follow treatment
electrolyte regimen for
imbalances from electrolyte
dehydration. This imbalances,
is indicative of administering
metabolic potassium
alkalosis which supplementation.
can happen from Treatment of
a loss of acid in dehydration to help
the body with levels return to
dehydration. baseline.
O2 93-100%
Glucose 70-100
non-
diabetic
Hgb A1c Goal <7%
for
diabetics
TSH 0.4-4.0
without
thyroid
disorder
T3 70-205
T4 4-12
LFTs
albumin 3.5-5g/dl 4.9
aLT 4-36 IU 15
AST 0- 20
 35units/L
Alkaline 30- 72
Phosphatase 120units/L
(ALP)
Total Bilirubin 0.3- 0.5
1.0mg/dl
Direct Bilirubin 0.1-
0.3mg/dl
Indirect 0.2-
Bilirubin 0.8mg/dl
Ammonia 10-80
Amylase 30-220
Lipase 0-160
Misc:

Diagnostic Test (i.e. CXR, CT, MRI, Doppler, ECHO, ECG, etc.)
Date Test Type Results Significance
9/30/20 @ EKG -Atrial Fibrillation Related to patient’s
2143 -Nonspecific ST and T wave electrolyte imbalances.
abnormality Hypokalemia can cause
-Prolonged QT interval or tu arrhythmias.
fusion, consider myocardial
disease, electrolyte
imbalance, or drug effects
-Abnormal ECG
-When compared with last
ECG, atrial fibrillation has
replaced normal sinus rhythm
9/30/20 @ PO Check PA or AP Similar left upper lung Imaging of patient’s MAC
2227 consolidation presumably infection in the lungs.
related to known MAC
infection. Better evaluated on
the 9/09/20 CT. No definite
new consolidation; however,
subtle superimposed change
in this region could be
difficult to appreciate.
10/01/20 @ EKG -Sinus rhythm with premature Related to patient’s
0704 atrial complexes electrolyte imbalances.
-Nonspecific ST abnormality Hypokalemia can cause
-Prolonged QT interval or tu arrhythmias. The
fusion, consider myocardial arrhythmia is improving
disease, electrolyte with the improvement in
imbalance, or drug effect potassium serum levels.
-Abnormal ECG
-When compared with ECG
 9/30/20 sinus rhythm has
replaced atrial fibrillation and
QT has shortened

Describe all abnormal assessment findings, what each one means and what you did about
each one. Indicate with a check in the box if it is related to admission diagnosis, sign client
is improving or sign client is worsening in their admission diagnosis.
Abnormal Significance Nursing Unrelated to Sign of Sign of
Assessment (what does the Interventions diagnosis potential worsenin
abnormal (what did you improvemen g
finding mean) do about the t condition
abnormal
finding)
Muscle This abnormal Treated the “Related to X – Patient
Cramps finding is patient’s admitting stated muscle
related to the critically low diagnosis.” cramps were
patient’s potassium with significantly
critically low IV and PO better than
potassium. potassium when he was
Hypokalemia chloride first admitted.
can cause supplementatio
muscle cramps, n. Continued to
fatigue, monitor.
generalized Encouraged
weakness, heart range of
palpitations, motion,
and atrial walking, and
fibrillation. exercise.
Muscle “” “” “” X – Patient
Soreness Muscle soreness stated
is related to soreness
patient’s muscle decreased
cramping. with decrease
Patient stated, in muscle
“muscles are cramping.
sore from ROM,
 cramping so walking, and
bad”. exercise also
helped
alleviate the
soreness.
Fatigue “” Treated the “” X – Patient
patient’s (Patient also still generally
critically low fatigued fatigued but
potassium with because he states it has
IV and PO was unable to improved.
potassium sleep well in Patient slept
chloride hospital bed, and napped
supplementatio complained less
n. Encouraged bed was very throughout
staying awake uncomfortabl the day.
during the day e)
and avoidance
of naps to help
sleep better at
night.
Generalized “” Treated the “” X – Patient
Weakness patient’s was still
critically low feeling weak
potassium with but states it
IV and PO has
potassium improved.
chloride Patient
supplementatio walked 1000
n. Encouraged ft with
independence. student nurse
Supervised in one
activities. occurrence
Encouraged and took
walks with walks with
four wheeled PT/OT.
walker. Significant
improvement.
Heart “” Treated the “” X – Patient
Palpitations patient’s stated he was
critically low having less
potassium with heart
IV and PO palpitations
potassium than he had
chloride been. On
supplementatio Friday, 10/2
n. Monitored he stated he
 heart rhythm had 2 or 3
through within my
telemetry shift in
monitoring and comparison
EKG’s. to a couple an
Thorough hour that he
cardiac complained
assessments. of on
admission.
Weakened Difficulty Treating X – Pulse
Pulse palpating radial dehydration pressure still
Pressure and dorsalis with PRN weak on
pedis pulses continuous IV Friday,
because the fluids. however
pulse pressure Encouraged pulse was
was weak. This patient to more
is a side effect continue oral noticeable
of dehydration. intake of during
fluids. palpitation.
Thorough
cardiac
assessments.
Atrial “” “” “” X – Patient’s
Fibrillation EKG showed
return to
normal sinus
rhythm with
premature
atrial
complexes
day after
admission
after being in
a-fib at
admission.
Edema in Edema is “” X – Noted a
bilateral feet related to (Related decrease in
and ankles chronic kidney because swelling
disease and hypokalemia between
heart failure. was caused Thursday and
Patient stated he by treatment Friday.
was of edema in Patient no
significantly lower longer had
more edematous extremities) indentation
prior to over from sock
diuresis. line present
 on Friday.
Neck pain This abnormal Offered patient X
finding was due Tylenol PRN
to the to assist with
uncomfortable pain control.
hospital beds. Patient
Patient declined at first
complained of attempt,
neck pain after reassessed later
awaking Friday on and wanted
morning. PRN Tylenol.
Patient stated he Encouraged
slept awful due patient to do
to ROM exercises
uncomfortable with his neck.
bed. Encourage
patient to get
up and
walking.
Offered hot
packs and
wrapped towel
around his
neck. Assisted
patient in find
more
comfortable
positions. Pain
ultimately
decreased with
interventions.
Burning A burning Potassium X – Related
Sensation sensation is a chloride to diagnosis
through IV common infusion was in the sense
line finding with IV diluted with that the IV
potassium NaCl 0.9%. potassium
chloride Hot packs were was running
infusion. administered to to reverse
keep over IV hypokalemia.
site to help.
Continued to
monitor IV site
for any
changes.
Dry mucous Patient was Advised for X – Fluids
membranes/ dehydrated use of PRN were stopped
 Complaints upon admission continuous IV on Friday
of dry because of the fluids to be morning
mouth over diuresis. run. because
Dry mucous Encouraged patient was
membranes are patient to intaking
symptoms of continue enough oral
dehydration. drinking water fluids to
to moisten oral rehydrate
mucosa. himself.
Offered use of Mucosa
Vaseline to membranes
moisten lips. still dry but
improvement
is seen.
Thirst This is related Advised for X–“”
to both the use of PRN
dehydration and continuous IV
hypokalemia. fluids to be
Thirst is the run.
first sign that Encouraged
the body is patient to
dehydrated. continue
Polydipsia is a drinking water
side effect of to moisten oral
hypokalemia. mucosa.

VS trends (include your 2 sets and hospitalization trends):

Vitals: Temperature Pulse Respiratory Rate Blood Pressure Pulse Oximetry
Previous Shift: 98.6 oral 84 18 123/72 96%
Current: 98.2 oral 74 16 110/70 96%
 Assessment Data
Objective:
-elevated BUN/CR
-hypokalemia
-hypochloremia
-dry mucus membranes
-dry skin
-decreased pulse
pressure/weak pulses
Subjective:
-thirsty
-c/o dry mouth even after
drinking full cup of water
while on IV fluids
-weakness
Priority:
Priority assessment data is
weakened pulse pressure
because this could be
indicative of shock.
Nursing Interventions
(What will the nurse do?)
1. Watch for early signs of
hypovolemia, including thirst,
restlessness, headaches, and
inability to concentrate. Thirst
is often the first sign of
dehydration.
2. Monitor pulse, respirations,
and blood pressure of clients
with deficient fluid volume
every 15 minutes to 1 hour for
the unstable client, every 4
hours for the stable client.
3. Observe for dry tongue and
mucous membranes, and
longitudinal tongue furrows.
4. Monitor total fluid intake
and output every 8 hours.
Recognize that urine output is
not always an accurate
Diagnosis
Problem Statement:
Deficient fluid volume
(p. 388-393, Ackley &
Ladwig)
Etiology:
Related to over diuresis of
kidneys to remove third
spacing fluid AEB dehydration
and electrolyte imbalances
secondary to heart failure.
Signs and Symptoms:
-dehydration
-elevated BUN/CR
-hypokalemia
-hypochloremia
-dry mucous membranes
-decreased pulse pressure
-c/o dry mouth
-c/o weakness
Supporting Rationale
(Reference/Source)
1. A study of healthy
volunteers who experienced a
fluid restriction of up to 37
hours reported symptoms of
headache, decreased alertness,
and inability to concentrate.
2. Vital signs changes seen
with fluid volume deficit
include tachycardia,
tachypnea, decreased pulse
pressure first, then
hypotension, decreased pulse
volume, and increased or
decreased body temperature.
3. These are symptoms of
decreased body fluids.
4. A urine output of less than
30 mL/hr is insufficient for
normal renal function and
Desired Outcomes
(What will the client do?)
1. Maintain a urine output of
more than 1300 mL/day or 30
mL/hr prior to discharge.
2. Maintain a normal blood
pressure, pulse, and body
temperature throughout shift.
3. Maintain elastic skin turgor;
moist tongue and mucous
membranes; and orientation to
person, place, and time prior to
discharge.
Evaluation Data
Date:
10/02/20 @ 1300
Outcome Summary:
Patient’s vital signs were
stable throughout the shift,
adequate urine output was met,
and patient was A&O x4.
Patient still has dry mucous
membranes and a slight delay
with skin turgor.
Revision:
Keep POC in place, continue
to monitor until patient has
meet all outcomes or until
discharge.
indicator or fluid balance.
Assessment Data
Objective:
-hypokalemia
-hypochloremia
-weakened pulse pressure
-elevated BUN/CR
-dry mucosa membranes and
skin
Subjective:
-c/o weakness
-c/o of thirst and dry mouth
Priority:
Priority assessment data is
weakened pulse pressure
because this could be
indicative of shock.
Nursing Interventions
(What will the nurse do?)
1. Monitor vital signs, blood
pressure, pulse, respirations,
indicates hypovolemia or onset
of renal damage.
Diagnosis Desired Outcomes
Problem Statement: (What will the client do?)
Risk for shock 1. Maintain a systolic blood
(p. 766-768, Ackley & pressure above 90 mmHg by
Ladwig) end of shift.
Etiology: 2. Maintain a heart rate
Related to hypovolemia and between 60-100 with a normal
dehydration AEB electrolyte sinus rhythm by end of shift.
abnormalities and AKI
secondary to over diuresis. 3. Have warm, dry skin prior
to discharge.
Signs and Symptoms:
-hypokalemia
-hypochloremia
-dry mucosa membranes
-c/o thirst and dry mouth
-weakened pulse pressure
-elevated BUN/CR
-c/o weakness
Supporting Rationale Evaluation Data
(Reference/Source) Date:
1. Elevated heart rate, 10/06/20 @ 1300
decreased blood pressure,
and pulse oximetry.
2. Maintain IV access.
Recognize that isotonic fluids
such as 0.9% normal saline or
ringers lactate rapidly may be
administered for a patient in
shock.
3. Complete a full nursing
physical examination
including examination of the
skin.
increased respiratory rate and
decreased SpO2 are indicators
of shock.
2. Adequate IV access is
required for fluid resuscitation
and medication delivery.
3. A full nursing assessment is
crucial in identifying multiple
complications of shock such
as: hypoperfusion of internal
organs that manifest as
decreased bowel sounds and
shortness of breath. Cool,
clammy skin and mottling are
symptoms of tissue
hypoperfusion. Pale, clammy
skin will be present in shock
states.
Outcome Summary:
This patient successfully
maintained a systolic blood
pressure above 90 mmHg and
a heart rate between 60-100
throughout the shift.
Patient’s skin is dry and cool
to touch, patient is cold
because of low fluid status.
Patient’s body temperature
should warm up as
dehydration reverses.
Revision:
POC is successful continue
until patient D/C.
Medical interventions used to treat admission problem/diagnosis (Consults, pharmacology,
surgery, treatments, therapy, etc.).

Patient consulted with infectious disease doctor regarding MAC infection, nephrology regarding
AKI and CKD, general practice doctor regarding electrolyte imbalances, as well as PT and OT.
Patient was given IV and PO potassium supplementation to assist in raising levels to baseline.
Lab draws of potassium were every 2 hours to monitor levels and ensure right dosing of
potassium supplementation. Renal diet was ordered with AKI and CKD. Continuous fluids were
ordered to assist with treating AKI and dehydration.

Nutrition (diet orders, supplements, tube feeding, restrictions, etc.) and why are they ordered:
List 5 examples of foods that should be restricted and/or encouraged based on ordered diet.

Patient was placed on a renal diet to assist with treatment of AKI. Renal diet includes potassium,
sodium, and phosphorus restrictions. Fluid restrictions may be implemented if needed. Do not
use additional salt in cooking or before eating. Try to use options that say, “no salt added”. Dairy
products are a major source of phosphorus in the diet, limit dairy intake. Avoid potassium rich
foods such as bananas, cantaloupe, oranges, tomatoes, pumpkin, and green leafy vegetables such
as cooked greens, spinach, kale, collards, and swiss chard.

Discharge plan for care (Case Management) **Discharge Plan starts on day 1:

Patient to discharge home tomorrow, 10/3, with wife if AKI resolves as hypokalemia has been
resolved.

Discuss client teaching provided (include client barriers to teaching):

I taught my patient extensively on AKI because he did not understand why that was a barrier to
him being discharged. I explained that the AKI occurred because of over diuresis which put a
significant strain on the kidneys to excrete an excessive amount of fluids. I also explained that
we wanted the AKI to be resolved prior to discharge because most medications are primarily
excreted through the urine/kidneys, so we want baseline kidney function for proper excretion of
medications. Patient is a CKD patient as well, so BUN and CR levels need to return to his
baseline not textbook baseline. He asked how we could look at his kidney function and I
explained the lab renal function tests of BUN and CR and that when these levels are elevated this
is indicative of an AKI. I reassured him that his levels were improving and compared his
admission BUN and CR to his present with him. Patient seemed very receptive of learning and
understood importance of treatment for AKI. Patient also concerned with taking his prescribed
antibiotics because his nephrologist had made a comment that he may discontinue the medication
if renal function levels do not improve. I explained to the patient that the medication has not been
discontinued at this point and explained the importance of taking and finishing antibiotic
regimen. I explained that renal levels have shown improvement and advised patient to continue
taking antibiotic until his doctor stated otherwise. Patient receptive of teaching. I also gave my
client the flu vaccine and provide verbal and written education. No client barriers to teaching.
Patient asked many questions to assist him in understanding his condition.
STUDENT EVALUATION OF CLINICAL PERFORMANCE (please list specific examples
for each clinical experience):

Explain how you met a QSEN competency during your clinical experience:

Teamwork and Collaboration: I worked very well with floor staff to ensure adequate patient care
was received. Patient was on frequent medication administrations with critically low potassium,
so I worked with staff RN and instructor to pass medications efficiently.

Safety: Assisted patient with multiple transfers and ambulating in the hallway. Gait belt and four
wheeled walker used with ambulation as well as gripper socks.

Informatics: I looked up a lot on CKD with a previous patient I had which gave me a very good
understanding of renal function labs and how the impairment effects medication excretion. This
assisted me in educating my client on his AKI and CKD. I also gave my client the flu vaccine
and provided verbal and written information/education. I also learned a lot with my patient’s
condition and how electrolyte imbalances present outside of a textbook.

After reflecting on your clinical performance today, what critical thinking did you utilize
and how can you improve on that in your next clinical day?

I used critical thinking with my patient in troubleshooting ways to deal with the burning of the
IV line and his muscle soreness such as the hot packs. I continuously checked the patient’s
potassium levels to ensure that the supplementation was still appropriate to give. Once the IV
potassium infusion was discontinued after levels returned to normal, the staff RN and I discussed
and decided to cap his PRN IV fluids with him having heart failure to prevent fluid overload.
 References

Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide
to planning care. Maryland Heights, MO: Mosby.

Bakris, G. L. (2019, October). High Blood Pressure - Heart and Blood Vessel Disorders.
Retrieved October 06, 2020, from https://www.merckmanuals.com/home/heart-and-blood-
vessel-disorders/high-blood-pressure/high-blood-pressure

Braunstein, E. M. (2020, September). Overview of Anemia - Blood Disorders. Retrieved October

06, 2020, from https://www.merckmanuals.com/home/blood-disorders/anemia/overview-
of-anemia?query=anemia

Chong, J. Y. (2020, July). Overview of Stroke - Brain, Spinal Cord, and Nerve Disorders.
Retrieved October 06, 2020, from https://www.merckmanuals.com/home/brain,-spinal-
cord,-and-nerve-disorders/stroke-cva/overview-of-stroke?query=stroke

Davidson, M. H. (2020, April). Dyslipidemia - Hormonal and Metabolic Disorders. Retrieved

October 06, 2020, from https://www.merckmanuals.com/home/hormonal-and-metabolic-
disorders/cholesterol-disorders/dyslipidemia?query=dyslipidemia

Edwards, N. (2020, May). Gout - Bone, Joint, and Muscle Disorders. Retrieved October 06,
2020, from https://www.merckmanuals.com/home/bone,-joint,-and-muscle-disorders/gout-
and-calcium-pyrophosphate-arthritis/gout?query=gout

Gout. (2019, March 01). Retrieved October 06, 2020, from https://www.mayoclinic.org/diseases-
conditions/gout/symptoms-causes/syc-20372897

Howlett, J. (2020, April). Heart Failure (HF) - Heart and Blood Vessel Disorders. Retrieved
October 06, 2020, from https://www.merckmanuals.com/home/heart-and-blood-vessel-
disorders/heart-failure/heart-failure-hf?query=diastolic+heart+failure

Lynch, K. L. (2019, July). Gastroesophageal Reflux Disease (GERD) - Digestive Disorders.

Retrieved September 30, 2020, from https://www.merckmanuals.com/home/digestive-
disorders/esophageal-and-swallowing-disorders/gastroesophageal-reflux-disease-gerd

Malkina, A. (2020, March). Chronic Kidney Disease - Kidney and Urinary Tract Disorders.
Retrieved October 06, 2020, from https://www.merckmanuals.com/home/kidney-and-
urinary-tract-disorders/kidney-failure/chronic-kidney-disease

Mycobacterium Avium Complex infections. (2020). Retrieved October 06, 2020, from
https://rarediseases.info.nih.gov/diseases/7123/mycobacterium-avium-complex-infections

Shields, K. M., Fox, K. L., & Liebrecht, C. (2019). Pearson Nurse's Drug Guide 2019. New
York, NY: Pearson.
Strohl, K. P. (2020, September). Sleep Apnea - Lung and Airway Disorders. Retrieved October
06, 2020, from https://www.merckmanuals.com/home/lung-and-airway-disorders/sleep-
apnea/sleep-apnea?query=obstructed+sleep+apnea

Tierney, D., & Nardell, E. (2018, June). Infections Caused by Bacteria Related to Tuberculosis
(TB) - Infections. Retrieved October 06, 2020, from
https://www.merckmanuals.com/home/infections/tuberculosis-and-related-
infections/infections-caused-by-bacteria-related-to-tuberculosis-tb?
query=mycobacterium+avium+complex