1
AZUSA PACIFIC UNIVERSITY
SCHOOL OF NURSING
GNRS 588: ADVANCED NURSING CARE FOR ADULTS
COMPREHENSIVE CARE PLAN #: ____2____
Student: Antonia Y Perez
Instructor: Professor Padilla
Date of Care: 03/22/2024
Date of Submission: 04/05/2024
, 2
Nursing Clinical Worksheet
Student Name: Antonia Y Perez Date: 03/22/2024
Patient Initials: Age: Sex: Isolation and Type: Code Status: Full Admit Date: 03/10/24
J.G 39 M Standard Weight: 118.2 kg
Allergies: Diet: Fall Risk: Braden Activity: LOC:
NKA NPO Yes Score: Sedated &
12 Unable to Unresponsive
RASS: -4 ambulate
currently placed
on Bed-Rest.
Admitting Diagnosis/Chief Complaint (if present in ED): 39 yr old presents hypothermic, with acute respiratory
distress, methamphetamine intoxication, and agitation.
ASSESSMENT DATA:
1. History of Present Problem: (notes: begin with what brought the patient to the hospital, what has been done since
admission, plan for what is coming up next + discharge planning if appropriate)
Initial Note: Patient is a 39 year-old-male with no known pertinent past medical history presented in ED on
03/10/2024 hypothermic and unresponsive, patient was noted to have UDS positive for TSH/meth upon arrival.
During stay patients’ agitation worsened, requiring intubation. Over the course of his stay in the intensive care unit,
patient has had multiple attempts to wean off the ventilator but has required persistent mechanical ventilation
secondary to agitation. Workup also concerning for multifocal pneumonia, and ARDs. Patient currently
intubated/sedated. On chest x-ray today, findings persistent with atelectasis and categories of ARDS.
3/22: Patient evaluated bedside, remains intubated/sedated on fentanyl/Precedex/propofol secondary to increased
agitation and hypoxemia. Improved ventilator settings. Will continue monitor for daily weaning. Family aware that
tracheostomy may be indicated.
2. Past Medical History
No known past medical history
What is the relationship of your patient’s past medical history (PMH) and current medications? Which medications
treat which conditions?
PMH Home Medications Pharm. Classification Expected Outcome
1. none applicable 1. 1. 1.
2. 2. 2. 2.
3. 3. 3. 3.
BEGINNING OF PATIENT CARE:
Doc Flowsheet Data
Vital Signs 0800 1200 1600 Ventilator Settings IV Fluids/Drips
Noninvasive Blood 134/59 135/64 140/63 Type Rate/ Site
Pressure (NIBP)
Mean Arterial Blood Mode: Press-Reg Sodium 3 ml
Pressure (MAP) Chloride RTQ6H
Pulse Rate 59 60 60
, 3
Respiration Rate (RR) 17 17 18
% O2 Saturation (SpO2) 98 98 98 Rate: Actual 17
Temperature 37.0 37.1 37.0 12.5 G
Hemodynamic 0800 0900 1000 1100 1200 Set: 14 Dextrose ASDIR
Monitoring water
Arterial Blood
Pressure (ABP) X X X X X TV: 480
Central Venus
Pressure (CVP) X X X X X
Pulmonary Artery
Pressure (PAP) X X X X X FiO2: 50
Pulmonary Artery Dexmedeto 96ml
Occlusion Pressure X X X X X midine ASDIR
(PAOP) PEEP: 14 (Precedex) RLA 22G
Cardiac Index
X X X X X Furosemide 40 mg
Cardiac Output (CO) PS: none applicable Daily
X X X X X
Other
Intracranial Pressure Propofol 100ml
(ICP) X X X X X ASDIR
Blood Glucose (POC) (H) IV
Pain Level
Fentanyl/ Titrate
Citrate IV
Intake ( ml per shift) Output (ml per shift)
Intake/
Output Oral Enteral IV TOTAL Urine BM Emesis Drains TOTAL
Output
Shift Total X X 624.7 624.7 1800 0 0 X 1800
Please state why there is a significant difference in the I/O (if any): There is no significant difference. Below are further significant
values towards patients intake and output balance.
Tube feeding : Not Currently Feeding Until Dr. Approves To Start It Again Due To Vomiting Last Night but Last
was 770ml.
HR Rhythm P wave PR QRS P:Q ratio ST T-wave Q-T Ectopy (Y/N)
(seconds) (#P :#Q) segment
(reg/irreg) (seconds) (seconds) (seconds) (seconds)
(seconds)
90 SR 0.08 0.16 0.08 1:1 0.02 0.20 0.38 No
Interpretation:
Normal Sinus Rhythm
Complete Head-To-Toe Assessment
AZUSA PACIFIC UNIVERSITY
SCHOOL OF NURSING
GNRS 588: ADVANCED NURSING CARE FOR ADULTS
COMPREHENSIVE CARE PLAN #: ____2____
Student: Antonia Y Perez
Instructor: Professor Padilla
Date of Care: 03/22/2024
Date of Submission: 04/05/2024
, 2
Nursing Clinical Worksheet
Student Name: Antonia Y Perez Date: 03/22/2024
Patient Initials: Age: Sex: Isolation and Type: Code Status: Full Admit Date: 03/10/24
J.G 39 M Standard Weight: 118.2 kg
Allergies: Diet: Fall Risk: Braden Activity: LOC:
NKA NPO Yes Score: Sedated &
12 Unable to Unresponsive
RASS: -4 ambulate
currently placed
on Bed-Rest.
Admitting Diagnosis/Chief Complaint (if present in ED): 39 yr old presents hypothermic, with acute respiratory
distress, methamphetamine intoxication, and agitation.
ASSESSMENT DATA:
1. History of Present Problem: (notes: begin with what brought the patient to the hospital, what has been done since
admission, plan for what is coming up next + discharge planning if appropriate)
Initial Note: Patient is a 39 year-old-male with no known pertinent past medical history presented in ED on
03/10/2024 hypothermic and unresponsive, patient was noted to have UDS positive for TSH/meth upon arrival.
During stay patients’ agitation worsened, requiring intubation. Over the course of his stay in the intensive care unit,
patient has had multiple attempts to wean off the ventilator but has required persistent mechanical ventilation
secondary to agitation. Workup also concerning for multifocal pneumonia, and ARDs. Patient currently
intubated/sedated. On chest x-ray today, findings persistent with atelectasis and categories of ARDS.
3/22: Patient evaluated bedside, remains intubated/sedated on fentanyl/Precedex/propofol secondary to increased
agitation and hypoxemia. Improved ventilator settings. Will continue monitor for daily weaning. Family aware that
tracheostomy may be indicated.
2. Past Medical History
No known past medical history
What is the relationship of your patient’s past medical history (PMH) and current medications? Which medications
treat which conditions?
PMH Home Medications Pharm. Classification Expected Outcome
1. none applicable 1. 1. 1.
2. 2. 2. 2.
3. 3. 3. 3.
BEGINNING OF PATIENT CARE:
Doc Flowsheet Data
Vital Signs 0800 1200 1600 Ventilator Settings IV Fluids/Drips
Noninvasive Blood 134/59 135/64 140/63 Type Rate/ Site
Pressure (NIBP)
Mean Arterial Blood Mode: Press-Reg Sodium 3 ml
Pressure (MAP) Chloride RTQ6H
Pulse Rate 59 60 60
, 3
Respiration Rate (RR) 17 17 18
% O2 Saturation (SpO2) 98 98 98 Rate: Actual 17
Temperature 37.0 37.1 37.0 12.5 G
Hemodynamic 0800 0900 1000 1100 1200 Set: 14 Dextrose ASDIR
Monitoring water
Arterial Blood
Pressure (ABP) X X X X X TV: 480
Central Venus
Pressure (CVP) X X X X X
Pulmonary Artery
Pressure (PAP) X X X X X FiO2: 50
Pulmonary Artery Dexmedeto 96ml
Occlusion Pressure X X X X X midine ASDIR
(PAOP) PEEP: 14 (Precedex) RLA 22G
Cardiac Index
X X X X X Furosemide 40 mg
Cardiac Output (CO) PS: none applicable Daily
X X X X X
Other
Intracranial Pressure Propofol 100ml
(ICP) X X X X X ASDIR
Blood Glucose (POC) (H) IV
Pain Level
Fentanyl/ Titrate
Citrate IV
Intake ( ml per shift) Output (ml per shift)
Intake/
Output Oral Enteral IV TOTAL Urine BM Emesis Drains TOTAL
Output
Shift Total X X 624.7 624.7 1800 0 0 X 1800
Please state why there is a significant difference in the I/O (if any): There is no significant difference. Below are further significant
values towards patients intake and output balance.
Tube feeding : Not Currently Feeding Until Dr. Approves To Start It Again Due To Vomiting Last Night but Last
was 770ml.
HR Rhythm P wave PR QRS P:Q ratio ST T-wave Q-T Ectopy (Y/N)
(seconds) (#P :#Q) segment
(reg/irreg) (seconds) (seconds) (seconds) (seconds)
(seconds)
90 SR 0.08 0.16 0.08 1:1 0.02 0.20 0.38 No
Interpretation:
Normal Sinus Rhythm
Complete Head-To-Toe Assessment
