CARE PLAN TEMPLATE
Student Date
Instructor Course N101L
Patient Initials J. D. Unit/Room 105B DOB 06/07/37 ______
Code Status Full Code Height/Weight 5’5”/140 lbs. ______________
Allergies Doxycycline (rash) and Vicodin (severe nausea)
Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10
102 F (orally) 112 BPM 32 RR 85% (at room air) 168/94 0 out of 10
(right radial) (right arm
manually)
History of Present Illness including Admission Diagnosis and Relevant Relevant Diagnostic Procedures & Surgeries /Results
Physical Assessment Findings (normal & abnormal) (include dates, if not found state so)
History of Present Illness: Diagnostic Procedures:
78 year old female with a 12 year history of emphysema, 30 year smoking
history, and 15+ years of hypertension (HTN). Patient’s neighbor called ABG Lab Tests – 10/12/11 0500
911 after seeing patient become extremely short of breath without Results:
exertion, coughing profusely with large amounts of mucous produced, pH – 7.33
intermittently removing cannula as it was not helping, appearing weak, PaO2 – 70
and not as mobile as normal. PaCO2 – 47
Family History: HCO3 – 26
Client’s mother deceased at 51 for Myocardial Infarction SpO2 – 92%
Client’s father deceased at 59 for respiratory failure (smoked for 40 years) Sputum sent for Gram Staining, Culture & Sensitivity - 10/12/11
Admission Diagnosis: 0530
Client admitted to hospital with moderate respiratory distress at 0300 Results: still pending
Physical Assessment Findings: Chest X Ray – 10/12/11 0530
Signs: client alert and oriented; showed labored and shallow respiratory Results: showed generalized hyperinflation and right middle and
effort with use of accessory muscles upon assessment; bilateral breath lower lobe infiltrates
sounds reveal coarse rales to right side; client is tachypneic and coughing Surgeries:
productively with thick yellow sputum; client has intermittent sleeping No surgeries ordered at this time
patterns
West Coast University Page 10
January 2015
,Symptoms: client complains of dryness to bilateral nares (removes nasal
cannula intermittently); only able to tolerate HOB up in fowler’s position;
client states she is anxious because of feeling SOB
Past Medical & Surgical History, Pathophysiology of medical diagnoses Pertinent Lab tests/ Results (with normal ranges)
(with APA citations) with dates and rationales
Past Medical History: Pertinent Lab Tests/Rationales:
Gravida 2 Para 2 no complications (2 pregnancies/2 live births)
Osteoporosis for the past 8 years Arterial Blood Gas (ABG) Lab Tests:
Hypertension for the past 15 years This test was taken to determine the respiratory status or the
Pneumonia (admitted multiple times in the past 3 years) acid-base balance of the client. If the primary focus is to evaluate
Client has smoked for the last 30 years (5 packs per week) the respiratory status of the client, then the PO2, PCO2, and pH
Emphysema for the past 12 years levels, as well as oxygen saturation, are the most important to
Surgical History: evaluate. If the primary focus is to evaluate a metabolic acid-base
Hysterectomy 20 years ago imbalance, the PO2 has little significance. The pH test measures
Pathophysiology of Medical Diagnoses: the alkalinity or acidity of the blood. Increased pH indicates a
Osteoporosis – state of alkalosis; decreased pH indicates that the client is in a
Osteoporosis is a metabolic bone disorder in which the rate of bone state of acidosis. The PaO2 (Partial Pressure of Oxygen) test
resorption accelerates and the rate of bone formation slows, causing a measures the amount of oxygen dissolved in the blood. Increased
loss of bone mass. Bones affected by this disease lose calcium and PaO2 indicates administration of high doses of oxygen; decreased
phosphate salts and become porous, brittle, and abnormally vulnerable to PaO2 (defined as less than 60 mm Hg.) could indicate ventilation
fractures. In normal bone, the rates of bone formation and resorption are to blood flow abnormalities in that oxygen is not reaching the
constant; replacement follows resorption immediately, and the amount of bloodstream. The PaCO2 (Partial Pressure of Carbon Dioxide) test
bone replaced equals the amount of bone resorbed. Osteoporosis measures the partial pressure of carbon dioxide in the arterial
develops when the remodeling cycle is interrupted and new bone blood. Increased PaCO2 indicates that the normal amount of
formation falls behind resorption. When bone is resorbed faster than it carbon dioxide is not being expired; decreased PaCO2 indicates
forms, the bone becomes less dense (Lippincott, Williams, & Wilkins, rapid, deep breathing while expelling high amounts of carbon
2011). dioxide. The HCO3 (bicarbonate) test measures the metabolic
Hypertension – component of the acid-base equilibrium. An increase in HCO3
Hypertension is an elevation in diastolic or systolic blood pressure. indicates a loss of hydrogen ions and a base excess; a decrease in
Arterial blood pressure is a product of total peripheral resistance and HCO3 is an indication of a base deficit. The SpO2 (Oxygen
cardiac output. Cardiac output is increased by conditions that increase Saturation) test measures the amount of oxygen carried by the
heart rate, stroke volume, or both. Peripheral resistance is increased by hemoglobin in the blood. Shunting of blood from the venous to
factors that increase blood viscosity or reduce the lumen size of vessels, the arterial system causes decreased oxygen saturation (Corbett,
especially the arterioles. Several theories help to explain the development 2008).
of hypertension, including: Date Test Taken: 10/12/11
West Coast University Page 10
January 2015
, Changes in the arteriolar bed, causing increased peripheral Client Results:
vascular resistance pH – 7.33
Abnormally increased tone in the sympathetic nervous system PaO2 – 70
that originates in the vasomotor system centers, causing PaCO2 – 47
increased peripheral vascular resistance HCO3 – 26
Increased blood volume resulting from renal or hormonal SpO2 – 92%
dysfunction According to Corbett in 2008, the normal ranges are as follows:
An increase in arteriolar thickening caused by genetic factors, pH – 7.35 - 7.45
leading to increased peripheral vascular resistance PaO2 – 80 – 100 mm Hg.
Abnormal rennin release, resulting in the formation of PaCO2 – 35 – 45 mm Hg.
angiotensin II, which constricts the arteriole and increases blood HCO3 – 21 – 28 mmol/L.
volume SpO2 – 96 – 100%
Prolonged hypertension increases the heart’s workload as resistance to Sputum sent for Gram Staining, Culture & Sensitivity:
left ventricular ejection increases. To increase contractile force, the left Sputum originates in the bronchi and different bacteria can cause
ventricle hypertrophies, raising the heart’s oxygen demands and the sputum to be greenish, yellowish, or rust-colored. The client’s
workload. Cardiac dilation and failure may occur when hypertrophy can sputum was sent for Gram staining to help identify the bacteria
no longer maintain sufficient cardiac output. Because hypertension and differentiate between Gram-negative or Gram-positive
promotes coronary atherosclerosis, the heart may be further bacteria. Sputum cultures are often ordered when a client has
compromised by reduced blood flow to the myocardium, resulting in lung congestion (crackles), elevated temperature, and other signs
angina or myocardial infarction (MI). Hypertension also causes vascular of a probable respiratory infection, which cause an increased
damage, leading to accelerated atherosclerosis and target organ damage, secretion of respiratory secretions or sputum. A culture allows the
such as retinal injury, renal failure, stroke, and aortic aneurysm and bacteria to grow and multiply so that the exact organism can be
dissection (Lippincott, Williams, & Wilkins, 2011). identified. In addition to knowing the exact organism causing
Pneumonia – possible infection, it is necessary to demonstrate if the organism
Pneumonia is an inflammation of the lung parenchyma associated with is sensitive to a certain antibiotic. Sensitivity refers to the ability
alveolar edema and congestion that impair gas exchange. Primary of the antibiotic to inhibit the growth of the bacteria. Labs check
pneumonia is caused by the client’s inhaling or aspirating a pathogen. the sensitivity of organisms to specific antibiotics by putting disks
Secondary pneumonia ensues from lung damage caused by the spread of of paper impregnated with antibiotics in a culture. The purpose of
bacteria from an infection elsewhere in the body. Likely causes include the client receiving a culture and sensitivity test is to ensure that
various infectious agents (bacterial, viral, or fungal), chemical irritants the client is receiving the correct antibiotic for the particular
(including gastric reflux/aspiration, smoke inhalation), and radiation organism causing the infection (Corbett, 2008).
therapy (Doenges, Moorhouse, & Murr, 2006). Date Test Taken: 10/12/11
Emphysema – Client Results: still pending
Emphysema, a form of chronic obstructive pulmonary disease, is the According to Corbett in 2008, the normal ranges are as follows:
abnormal, permanent enlargement of the acini accompanied by Gram-stain – NEGATIVE result indicates no bacteria/no
West Coast University Page 10
January 2015
Student Date
Instructor Course N101L
Patient Initials J. D. Unit/Room 105B DOB 06/07/37 ______
Code Status Full Code Height/Weight 5’5”/140 lbs. ______________
Allergies Doxycycline (rash) and Vicodin (severe nausea)
Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10
102 F (orally) 112 BPM 32 RR 85% (at room air) 168/94 0 out of 10
(right radial) (right arm
manually)
History of Present Illness including Admission Diagnosis and Relevant Relevant Diagnostic Procedures & Surgeries /Results
Physical Assessment Findings (normal & abnormal) (include dates, if not found state so)
History of Present Illness: Diagnostic Procedures:
78 year old female with a 12 year history of emphysema, 30 year smoking
history, and 15+ years of hypertension (HTN). Patient’s neighbor called ABG Lab Tests – 10/12/11 0500
911 after seeing patient become extremely short of breath without Results:
exertion, coughing profusely with large amounts of mucous produced, pH – 7.33
intermittently removing cannula as it was not helping, appearing weak, PaO2 – 70
and not as mobile as normal. PaCO2 – 47
Family History: HCO3 – 26
Client’s mother deceased at 51 for Myocardial Infarction SpO2 – 92%
Client’s father deceased at 59 for respiratory failure (smoked for 40 years) Sputum sent for Gram Staining, Culture & Sensitivity - 10/12/11
Admission Diagnosis: 0530
Client admitted to hospital with moderate respiratory distress at 0300 Results: still pending
Physical Assessment Findings: Chest X Ray – 10/12/11 0530
Signs: client alert and oriented; showed labored and shallow respiratory Results: showed generalized hyperinflation and right middle and
effort with use of accessory muscles upon assessment; bilateral breath lower lobe infiltrates
sounds reveal coarse rales to right side; client is tachypneic and coughing Surgeries:
productively with thick yellow sputum; client has intermittent sleeping No surgeries ordered at this time
patterns
West Coast University Page 10
January 2015
,Symptoms: client complains of dryness to bilateral nares (removes nasal
cannula intermittently); only able to tolerate HOB up in fowler’s position;
client states she is anxious because of feeling SOB
Past Medical & Surgical History, Pathophysiology of medical diagnoses Pertinent Lab tests/ Results (with normal ranges)
(with APA citations) with dates and rationales
Past Medical History: Pertinent Lab Tests/Rationales:
Gravida 2 Para 2 no complications (2 pregnancies/2 live births)
Osteoporosis for the past 8 years Arterial Blood Gas (ABG) Lab Tests:
Hypertension for the past 15 years This test was taken to determine the respiratory status or the
Pneumonia (admitted multiple times in the past 3 years) acid-base balance of the client. If the primary focus is to evaluate
Client has smoked for the last 30 years (5 packs per week) the respiratory status of the client, then the PO2, PCO2, and pH
Emphysema for the past 12 years levels, as well as oxygen saturation, are the most important to
Surgical History: evaluate. If the primary focus is to evaluate a metabolic acid-base
Hysterectomy 20 years ago imbalance, the PO2 has little significance. The pH test measures
Pathophysiology of Medical Diagnoses: the alkalinity or acidity of the blood. Increased pH indicates a
Osteoporosis – state of alkalosis; decreased pH indicates that the client is in a
Osteoporosis is a metabolic bone disorder in which the rate of bone state of acidosis. The PaO2 (Partial Pressure of Oxygen) test
resorption accelerates and the rate of bone formation slows, causing a measures the amount of oxygen dissolved in the blood. Increased
loss of bone mass. Bones affected by this disease lose calcium and PaO2 indicates administration of high doses of oxygen; decreased
phosphate salts and become porous, brittle, and abnormally vulnerable to PaO2 (defined as less than 60 mm Hg.) could indicate ventilation
fractures. In normal bone, the rates of bone formation and resorption are to blood flow abnormalities in that oxygen is not reaching the
constant; replacement follows resorption immediately, and the amount of bloodstream. The PaCO2 (Partial Pressure of Carbon Dioxide) test
bone replaced equals the amount of bone resorbed. Osteoporosis measures the partial pressure of carbon dioxide in the arterial
develops when the remodeling cycle is interrupted and new bone blood. Increased PaCO2 indicates that the normal amount of
formation falls behind resorption. When bone is resorbed faster than it carbon dioxide is not being expired; decreased PaCO2 indicates
forms, the bone becomes less dense (Lippincott, Williams, & Wilkins, rapid, deep breathing while expelling high amounts of carbon
2011). dioxide. The HCO3 (bicarbonate) test measures the metabolic
Hypertension – component of the acid-base equilibrium. An increase in HCO3
Hypertension is an elevation in diastolic or systolic blood pressure. indicates a loss of hydrogen ions and a base excess; a decrease in
Arterial blood pressure is a product of total peripheral resistance and HCO3 is an indication of a base deficit. The SpO2 (Oxygen
cardiac output. Cardiac output is increased by conditions that increase Saturation) test measures the amount of oxygen carried by the
heart rate, stroke volume, or both. Peripheral resistance is increased by hemoglobin in the blood. Shunting of blood from the venous to
factors that increase blood viscosity or reduce the lumen size of vessels, the arterial system causes decreased oxygen saturation (Corbett,
especially the arterioles. Several theories help to explain the development 2008).
of hypertension, including: Date Test Taken: 10/12/11
West Coast University Page 10
January 2015
, Changes in the arteriolar bed, causing increased peripheral Client Results:
vascular resistance pH – 7.33
Abnormally increased tone in the sympathetic nervous system PaO2 – 70
that originates in the vasomotor system centers, causing PaCO2 – 47
increased peripheral vascular resistance HCO3 – 26
Increased blood volume resulting from renal or hormonal SpO2 – 92%
dysfunction According to Corbett in 2008, the normal ranges are as follows:
An increase in arteriolar thickening caused by genetic factors, pH – 7.35 - 7.45
leading to increased peripheral vascular resistance PaO2 – 80 – 100 mm Hg.
Abnormal rennin release, resulting in the formation of PaCO2 – 35 – 45 mm Hg.
angiotensin II, which constricts the arteriole and increases blood HCO3 – 21 – 28 mmol/L.
volume SpO2 – 96 – 100%
Prolonged hypertension increases the heart’s workload as resistance to Sputum sent for Gram Staining, Culture & Sensitivity:
left ventricular ejection increases. To increase contractile force, the left Sputum originates in the bronchi and different bacteria can cause
ventricle hypertrophies, raising the heart’s oxygen demands and the sputum to be greenish, yellowish, or rust-colored. The client’s
workload. Cardiac dilation and failure may occur when hypertrophy can sputum was sent for Gram staining to help identify the bacteria
no longer maintain sufficient cardiac output. Because hypertension and differentiate between Gram-negative or Gram-positive
promotes coronary atherosclerosis, the heart may be further bacteria. Sputum cultures are often ordered when a client has
compromised by reduced blood flow to the myocardium, resulting in lung congestion (crackles), elevated temperature, and other signs
angina or myocardial infarction (MI). Hypertension also causes vascular of a probable respiratory infection, which cause an increased
damage, leading to accelerated atherosclerosis and target organ damage, secretion of respiratory secretions or sputum. A culture allows the
such as retinal injury, renal failure, stroke, and aortic aneurysm and bacteria to grow and multiply so that the exact organism can be
dissection (Lippincott, Williams, & Wilkins, 2011). identified. In addition to knowing the exact organism causing
Pneumonia – possible infection, it is necessary to demonstrate if the organism
Pneumonia is an inflammation of the lung parenchyma associated with is sensitive to a certain antibiotic. Sensitivity refers to the ability
alveolar edema and congestion that impair gas exchange. Primary of the antibiotic to inhibit the growth of the bacteria. Labs check
pneumonia is caused by the client’s inhaling or aspirating a pathogen. the sensitivity of organisms to specific antibiotics by putting disks
Secondary pneumonia ensues from lung damage caused by the spread of of paper impregnated with antibiotics in a culture. The purpose of
bacteria from an infection elsewhere in the body. Likely causes include the client receiving a culture and sensitivity test is to ensure that
various infectious agents (bacterial, viral, or fungal), chemical irritants the client is receiving the correct antibiotic for the particular
(including gastric reflux/aspiration, smoke inhalation), and radiation organism causing the infection (Corbett, 2008).
therapy (Doenges, Moorhouse, & Murr, 2006). Date Test Taken: 10/12/11
Emphysema – Client Results: still pending
Emphysema, a form of chronic obstructive pulmonary disease, is the According to Corbett in 2008, the normal ranges are as follows:
abnormal, permanent enlargement of the acini accompanied by Gram-stain – NEGATIVE result indicates no bacteria/no
West Coast University Page 10
January 2015
