Demography: A patient 66yrs old male with a past medical history of alcohol abuse since age 25, homeless, with history of hypertension was brought by the paramedic,

who report that he was walking home and got picked up from the ground. Pt unable to recall what happened. All he recalls is he fell and hit his shoulder, denies lost

of consciousness but unable to recall incident. On arrival to the hospital the pt blood pressure was 206/120, CT to the head was done which revealed atrophy and small

vessel ischemic changes and multiple lacunar infarcts. Ct of the cervical spine reveals no evidence of fracture. At time of examination the patient complained of pain

in the shoulder. The patient was very slow to respond knows he is in the hospital and date but not able to recall.
History of present illness: hypertension, history of alcohol use , history of fall.
Past surgical history: history of ankle surgery
Admitting diagnosis: Right shoulder pain
Course of current hospitalization to date: A male patient old, apparently fell yesterday and taken to the hospital by paramedics, upon admission, patient was found to

be disoriented given inconsistence answers to simple questions and hence neurological appointment was made, he complained of pain at the right shoulder but denies

headache, tingling, parathesias or any paralysis on his side. CT scan of the head and basic workup was done and revealed atrophy and small vessel ischemic changes and

multiple lacunar infarcts. X-ray done to right shoulder done to right shoulder during admission, no dislocation or fracture is seen, but there is moderate degeneration

and fraying of the glenoid labrium. Patient has been ordered to follow up with orthopedic doctor, due to recurrent falls and diffuse elevated reflexes with reduced

range of motion to the right arm. Follow up with neurologist for altered mental status and confusion, slow to respond and multiple lacunar by CT scan. Patient is to

follow up with psychiatrist to assess for behavior problems. Patient will have physical therapist, occupational therapist and speech therapist evaluate. Nephrologist

to check for renal function due to abnormal BUN and Creatinine 42 and 2.3 respectively, case manager.
Medications are amlodipine 10mg, Aspirin 81mg, clonidine 0.1mg q6h, and hydralazine 20mg IV q6hr
Lab report
Most Recent Significant /Recent Lab Results:  (Chemistry?  Hematology?  Drug Levels? Coagulation tests?)
Date    Lab Test    Results    Norms    Comments
5/18/2014    Hemoglobin     13.3    12-16.5    Within normal range
Hematocrit     39.4    36-46    Within normal range
Platelet count    421    140-440    With in normal range
MCV    89.3    81-95    With in normal range
MCH    30.4    28-32    With in normal range
RDW     13.5    11.5-14.5    With in normal range
Sodium    133    132-143    With normal range
Potassium plasma     4,4    3.5- 5.5    With normal range
creatinine    2.3    0,6-1.3    Above normal range
Blood urea nitrogen    42    6-22    Above normal range
Albumin     4.1    3.2-4.9    Within normal range
Triponin     0.02

Medication
Amlodipine 10mg (Norvasc) : is in the calcium channel blockers class. It is used to control blood pressure by relaxing the blood vessel to prevent the heart to pump

too hard and chest pain( angina) by pumping enough blood to the heart. Side effects are dizziness, drowsiness, and headaches, stomach upset, swollen in the hand,

ankles, lower legs and feet. Nursing implication: to monitor blood pressure for therapeutic effect, 2) monitor for side effect such as edema which can be accompanied

by weight gain. Report any postural hypotension 3) assess for heart palpitations
Patient teaching: 1) call primary physician when face swelling and lower legs are notice. 2) eat before taking medication is upset stomach 3) call if any irregular

heart beat nausea or constipation. 4) should get up slowing to prevent dizziness and fall.

Chamberlain College of Nursing

NR340 Critical Care Nursing

Interdisciplinary Care Assignment Guidelines
PURPOSE This purpose of this assignment is for the student to present a complete picture of nursing care of a critically-ill individual encountered during the course.

The student will demonstrate clinical reasoning skills and will discuss interdisciplinary care that had been incorporated and/or anticipated during the care of the

critically-ill individual. COURSE OUTCOMES This assignment enables the student to meet the following course outcomes: CO 1: Provide nursing care to patients and their

families in critical and emergent care settings based on theories and principles of nursing and related disciplines. CO 2: Initiate the use of appropriate resources in

direct care responsibilities within critical-care and emergent care settings. CO 3: Demonstrate effective therapeutic communication and relationship skills in

providing care to patients and families in critical-care and emergent care settings. CO 4: Demonstrate effective clinical decision-making based on critical thinking

skills and legal, ethical and professional standards and principles when caring for patients and families in critical care and emergent care settings. CO 5: Implement

a plan of for continued personal, professional, and educational development related to nursing practice within critical-care and emergent care settings. CO 7: Use

evidence including research findings from nursing and related disciplines to answer clinical questions related to nursing care of patients in critical care and

emergent care settings.

DUE DATE: See Course Calendar. This assignment falls within the college’s Late Assignment Policy. TOTAL POINTS POSSIBLE: 100 POINTS
Background Information on the critically-ill Individual: • Demographics • History of present illness • Relevant past medical and surgical history • Admitting

diagnosis(es) • Course of current hospitalization to date • Review of systems (ROS) with rationale for abnormal findings • Assessment findings during day(s) of care.

Includes vital signs, focused assessment, and data from monitoring devices. Laboratory and Diagnostic Tests Identify and list all lab values and diagnostic

tests/procedures performed. Include the rationales for performing the tests and for any abnormal results. Provide an analysis of the relationships between/among the

diagnostic tests and lab results with the critically-ill individual’s current condition(s). Medications Indicate the trade name and generic name, the medication

classification, the therapeutic use, major adverse effects, the nursing implications, and patient teaching. Also include the rationale(s) as to why the medication
NR340 Interdisciplinary Care Assignment Guidelines.docx Revised 07/08/2013 RC-AG/slp

REQUIREMENTS: THE FOLLOWING ELEMENTS MUST BE INCLUDED IN THE PAPER

1

Chamberlain College of Nursing

NR340 Critical Care Nursing

is prescribed for treatment. For example, document the rationale for how the treatment corrects the critically-ill individual’s condition or a side effect of another

drug that is prescribed for treatment. Nursing Diagnoses In order of priority, identify three (3) nursing diagnoses for the plan of care. The nursing diagnoses may

include “Risk for” and “Potential Complications” (PCs). Include three (3) nursing outcomes, a minimum of three (3) nursing interventions, and a minimum of three (3)

collaborative interventions for each nursing diagnosis or potential complication. Interventions Routine Nursing Management Describe independent nursing care you

provided in the care of the critically-ill individual. Examples include, but are not limited to: activity level, position, ongoing monitoring, nutrition (prescribed

diet, tube feedings/TPN, formula, rate and calculation of basal energy expenditure (BEE), patient education, wound care etc. The rationale must be included for each

intervention. Interdisciplinary (ID) Care Collaborative Management Identify the members of the interdisciplinary team caring for the critically-ill individual. Provide

a brief description of their roles and responsibilities. Interdisciplinary team members include, but are not limited to: physician, pharmacist, lab/diagnostic tests

personnel, respiratory therapy, physical therapy, occupational therapy, speech therapy, social work/case management, pastoral care, ethicist, etc. Therapeutic

Modalities Describe the various therapeutic modalities used in the management of care for the critically-ill individual. Discuss the extent of the nurse’s

responsibilities and skills required to manage the therapeutic modality in comparison to the responsibilities of the members of the interdisciplinary team. Therapeutic

modalities include but are not limited to: oxygen therapy (mode, FiO2,), dialysis/CRRT (settings), ventilator therapy (mode of ventilation, settings, FiO2). The

rationale must be included for each modality. Nursing Role Reflection Provide a brief summary of how your role interacted with the members of the interdisciplinary

team. Include in your summary • Analysis of communication style preferences among interdisciplinary team members and with the critically-ill individual and family

members. What is the impact of your own communication style on others? • System barriers and facilitators. Did the organizational framework for interdisciplinary

management of care facilitate or hindered the quality of care/outcomes for the critically-ill individual? What recommendations can you make to the organizational

system for enhancing interdisciplinary collaboration? Provide at least two (2) evidence-based literature items to support your recommendations. • Professional

Development. Based on your experience(s), write ideas for your own professional selfdevelopment plan to enhance your potential for becoming an effective member in an

interdisciplinary team.