NRS 426 Care for Adults with Complex Illness or Injury

Person/Family Centered Clinical Paperwork

Student Name:Makaylah Hoang Unit: MSU Clinical Instructor: Serena Garza

Patient Information (gather from EHR locations – Pt banner, H&P, Progress Notes, etc.):

Patient Initials: Ro, Hu Admit Date: 04.05.25 Ht: 71 in (180.34 cm)

Room #: 4A212-1 Primary Service: Medical Observation Wt: 196.2 ( 89.27 kg)
Age/Gender: M BMI: 27.51

Code Status: Full | DNR | Other (specify):

Allergies: NKA | Yes (specify): hydroclorothiazide, sulfa drugs, allopurinol, febuxistat, simvastatin, rosuvastatin

Isolation Precautions: standard precautions Reason: standard

Primary Language: english Interpreter Required: no

Medical, Surgical, & Social Hx (list conditions & hx of other comorbidities):

- Hx of: HIV, HTN, HLD, T2DM, G6PD Anemia, Gout, Colonic polyps, BRBPR
- Diverticular bleed in 03/31/2024 requiring clipping
- Hospitalization in 01/2025 & 02/2025 requiring blood transfusions
- Chronic stiff neck
Hx of Present Illness (why did pt come to hospital, what were the chief complaints, and clinical manifestations related):
Presented to ED for Hematochezia, dizziness, & weakness.
Pt stated has BRBPR (bright red blood per rectum) since 4/3/25. BM one day with large blood clot
Denys abd pain denies use of blood thinners, NSAIDs.
Current Medical Dx (admitting dx, condition(s) pt is being currently treated for) and two comorbidities:
- Rectal bleeding
- HLD
- Gout
- HTN
Course of Hospitalization (include details of what occurred throughout the length of stay, include procedures and
surgeries if applicable with dates and POD):
- Consent for blood products form signed and scanned on 04/05/25

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 NRS 426 Care for Adults with Complex Illness or Injury
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Current Patient Care Orders (gather from EHR where orders are listed):

Vital Signs: qShift | q1hr | q4hr | q12hr | Other: _______

Continuous Monitoring: N/A | Pulse Oximetry | Cardiac
Activity: As Tolerated/Ad Lib | Bedrest | Ambulate | Up to Chair (freq ____) | Spinal Prec. | Sternal Prec | Seizure Prec. |
HOB up >____ | Turn q2hr | CPM | ROM | Bed Alarm | Other: __walk TID per nurse mobility assessment__

Diet: Clear Liquid diet Reason: rectal bleeding

Fingerstick Blood Sugars: N/A | AC & HS | q____hr
Supplement: N/A | Type __________
Fluid Restriction: _________mL/day Reason:
Intake & Output: Routine/qShift | Strict | q_____ hr

Tube Feeds: N/A | Type (brand) ______________

Continuous Rate: __________mL/hr | Bolus: _____mL q__________hr |
H2O flush: __________mL q__________hr | Check Residuals: q__________hr
Neuro Checks: N/A | q__6_hr Type: Neurological | Neurovascular
Dialysis: N/A | Hemodialysis | Peritoneal Dialysis | Days __________
Wound/Drain Care: N/A | Yes (specify details in LDA/Wounds tables):

Other Notable Patient Care Orders:

- Pt at low risk for VTE
- CPAP/BIPAP: pressure settings PAP 10cmH2O no supplemental O2 required

Interdisciplinary Consults & reason (i.e. additional medical consulting services and interdisciplinary care such as RT, PT,
OT, dietary, etc.):
- Gastroenterology: consult request for gastrointestinal hemorrhage unspecified

Discharge Plan/Barriers to Discharge (what is the plan for discharge or transfer to lower level of care? Are there any
barriers?):
- Ongoing rectal bleeding unknown source/ BM with blood
- Decreased musculoskeletal mobility tolerance/ strength

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Prep Day/Clinical Day Assessment (last 24hrs progress notes & flowsheets):
Prep Day data needs to be completed during Prep Day. Clinical Day is to be completed during clinical based on clinical
experience with the patient and family.

Vital Signs
VS: Prep day, VS Clinical day VS Clinical day VS Clinical day
24-hour (high/low) Time:0732 Time:1201 Time:
Temperature 98.4 97.4 97.6 97.8
Pulse 80 89 89 83
Respiratory Rate 18 17 18 16
BP (SBP/DBP) 130/66 119/63 115/64 103/52
MAP - 85 93 74
SpO2 (%) 98 100 97 99
O2 Source Room air RA RA RA
O2 L/min - - - -
FiO2 - - - -
Pain 0 0 0 0
Pain scale - 0 0 0
POSS - - - -
RASS 0 – alert and calm 0 Calm & Coop 0 Calm & Coop 0 Calm & Coop
CAM - - - -
(Positive/Negative)

Prep Day Clinical Day

(At week 4, with CI approval, students may (At week 4, with CI approval, students may
document assessments by exception) document assessments by exception)

Neuromusculoskeletal

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 NRS 426 Care for Adults with Complex Illness or Injury
Person/Family Centered Clinical Paperwork
Neurological Assessment: WNL/EX Neurological Assessment: WNL/EX
LOC: alert LOC: alert
Orientation: x4 Orientation: x4
Speech: not charted Speech: no difficulty speaking
Swallow: not charted Swallow: no difficulty swallowing
GCS: not charted GCS:
Pupils: not charted Pupils: PERRL
Extremity Strength: Extremity Strength:
- Grip: strong - Grip: strong
o UEB: full strength o UEB: full strength
o LEB: full strength o LEB: full strength
- Sensation: - Sensation:
o UEB: intact o UEB: intact
o LEB: intact o LEB: intact
- Temperature: - Temperature:
o UEB: warm o UEB: warm
o LEB: warm o LEB: warm
Mobility/Assistive devices: Mobility/Assistive devices: cane
Fall Risk Score: = __________ High | Med | Low Fall Risk Score: = ___45+___ High | Med | Low
- Not charted CNS clinical manifestations?
CNS clinical manifestations? - Stand with only support (unsteady or requires verbal
cueing)
- Stand with only support (unsteady or requires
- Unable to mark and step independently
verbal cueing)
- Unable to mark and step independently Increased fatigue
Ortho Devices? Cane / walker Ortho Devices? Cane/walker
Neuro: Lines/Drains/Tubes? (detail in LDA) Neuro: Lines/Drains/Tubes? (detail in LDA)

Cardiovascular

Cardiovascular Assessment: WNL/EX Cardiovascular Assessment: WNL/EX

Rate: regular rate Rate: 89
Rhythm: regular rhythm Rhythm: regular
Heart Sounds: normal S1S2 Heart Sounds: s1s2
Capillary Refill (location/grade): all 4 extremities less Capillary Refill (location/grade): all 4 extremities less
than equal to 3 seconds than equal to 3 seconds
Pulses (location/grade): all 4 extremities, 3+ normal Pulses (location/grade): all 4 extremities, 3+ normal
Edema (location/grade): none Edema (location/grade): none
Cardiac Clinical Manifestations? Cardiac Clinical Manifestations?

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Cardiac lines/drains/tubes? (detail in LDA) Cardiac lines/drains/tubes? (detail in LDA)

Respiratory

Respiratory Assessment: WNL/EX Respiratory Assessment: WNL/EX

Rate: 18 Rate: 18
Rhythm: unlabored Rhythm: regular
Depth/Effort: normal depth/ regular rate Depth/Effort: unlabored
Breath Sounds: Breath Sounds:
- Auscultated: Anterior Only - Auscultated: Anterior and posterior
o RUL: clear o RUL: clear
o RML: clear o RML: clear
o RLL: clear o RLL: clear
o LUL: clear o LUL: clear
o LLL: clear o LLL: clear
Respiratory Clinical Manifestations? Respiratory Clinical Manifestations?
Respiratory lines/drains/tubes? Airway? (detail in LDA) Respiratory lines/drains/tubes? Airway? (detail in LDA)

Gastrointestinal

Abdominal Assessment: WNL/EX Abdominal Assessment: WNL/EX

Abd Description: rounded soft nontender Abd Description: Round
Bowel Sounds: all 4 quadrants active bowel sounds Bowel Sounds:
- RUQ: - Active all 4 quadrants
- RLQ: - Following Endoscopy: Hypoactive
- LUQ:
Last BM: 04/07/25
- LLQ:
Stool Description: reported by patient unwitnessed.
Last BM: 04/06/25
Clear liquid
Stool Description:
GI Clinical Manifestations?
- Description: liquid semi formed
- Pt prescribed Golytely GI prep
- Color: blood-tinged
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GI Clinical Manifestations? Gastrointestinal lines/drains/tubes? (detail in LDA)
- Pt stated he has blood in his stool
Gastrointestinal lines/drains/tubes? (detail in LDA)

Genitourinary

Genitourinary Assessment WNL/EX Genitourinary Assessment WNL/EX

- Only charted continent Urine Description (Odor/clarity/amount)
Urine Description (Odor/clarity/amount) - Clear/ yellow/ 300 mL
- 04/05/25 admission: Dialysis Access: n/a
Dialysis Access: n/a Urine Output for shift: 600ml
Urine Output for shift: GU Clinical Manifestations:
GU Clinical Manifestations: - Pt placed on NPO. Liquid only with medication
Urinary lines/drains/tubes (detail in LDA) Urinary lines/drains/tubes (detail in LDA)

Skin

Integumentary Assessment: WNL/EX Integumentary Assessment: WNL/EX

Skin Integrity: intact Skin Integrity: intact
Skin Color: usual for ethnicity Skin Color: normal for ethnicity
Moisture/Temp/Turgor: normal/ warm/ elastic ( Moisture/Temp/Turgor: normal/ warm/ normal turgor
normal/immediate)
Braden (Skin) Score: = ___18___ High | Med | Low
Braden (Skin) Score: = _____19____ High | Med | Low
Pressure Injury Prophylaxis: Ambulate TID
Pressure Injury Prophylaxis:
Integumentary Clinical Manifestations?
Integumentary Clinical Manifestations?
Wounds (Detail in Wounds)
Wounds (Detail in Wounds)

Other Assessments

Diet/percent consumed: Diet/percent consumed: NPO

FBG Reading (24-hr range): FBG Reading(s): 119
Previous 24-hr I&O: Intake +____1360_______mL I&O (current shift): Intake +___0____mL
Output -__1 voids_mL Net -/+ ___________mL Output -___600__mL Net -/+ ___-600__mL
Not calculation for net I&O on charting system VTE Prophylaxis: None | SCDs | Meds _________
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VTE Prophylaxis: None | SCDs | Meds __________ - ‘Pt at low risk for VTE. Education on benefit of
early ambulation’
- ‘Pt at low risk for VTE. Education on benefit of
early ambulation’

Lines/Drains/Airways LDA’s
Device Type Insertion Size/Location Your Assessment Your Other Details
Date Intervention
Vascular Access
PIV 04/05/25 Left, AC 20G Clean, dry, intact, Continue to monitor
patent ensure patency. Flush
with 10cc NS.
PIV 04/05/25 Right, Forearm Clean, dry, intact, Continue to monitor
20G patent ensure patency. Flush
with 10cc NS.
Other LDA’s

Wounds
Wound Type Location Dressing Type/Date Wound Care Your Your Intervention
of last dressing Orders Assessment
change

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Person/Family Centered Clinical Paperwork
List lab values ordered (normal & abnormal) and diagnostics from Admission, Prep Day, Clinical Day:
Indicate abnormal values as High/Low with highlighter/red ink or arrows. Explain how abnormal values relate to your
SPECIFIC patient, with citation. Note: “Normal Values” may vary per agency. Include references

Test (defined limits) Admission Prep Day Clinical Day Explanation/Out of Range
CHEMISTRY (CMP/BMP):
Sodium (135 - 145) 143 142 142 WDL
Potassium (3.5 - 5.5) 4.3 4.5 4.6 WDL
108 112 107 High- This may/could
indicate dehydration, Kidney
disease, Cushing syndrome,
metabolic acidosis,
Chloride (95 - 110)
respiratory alkalosis. Occur
when water loss exceed
sodium & chloride loss.
(Nagami, 2016)
23 21 19 Low- This could indicate a
mild respiratory alkalosis,
where there is a lower level
Carbon Dioxide, Blood (24 - 32) of carbon dioxide in the
blood, which can be due to
hyperventilation or other
respiratory conditions
Urea Nitrogen, Blood (8 - 22) 17 12 8 WDL
Creatinine, Blood (0.44 - 1.27) 1.4 1.1 1.2 WDL
129 123 131 High- indicate number of
conditions, including
diabetes, or other issues
Glucose, Blood (70-99)
that affect insulin or
glucose levels (Mayo
Clinic, 2022)
Calcium (8.6 - 10.5) 8.8 8.7 8.7 WDL
Albumin (3.4 – 4.6) - - - -
Total Protein (6.3 - 8.3) - - - -
Alkaline Phosphatase (35 - 115) - - - -
Aspartate Transaminase (15 - 43) - - - -
Alanine Transferase (6 - 63) - - - -
Bilirubin, Total (0.3 - 1.3) - - - -
Bilirubin, Direct (0 - 0.2) - - - -
Phosphorus (2.4 – 5.0) – Special Test - - - -
Magnesium (1.5 - 2.6) – Special Test 2.0 - 2.0 WDL
CHOLESTEROL PANEL:
Total Cholesterol (<200) - - - -
Triglycerides (35 - 160) - - - -
LDL (<130) - - - -
HDL (>40) - - - -
DIGESTIVE ENZYMES:
Amylase (33 - 130) - - - -
Lipase (13 - 51) - - - -
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HEMATOLOGY (CBC):
WBC (4.5 - 11.0) 6.1 7.0 9.3 WDL
2.94 3.21 2.92 Low- Anemia (low iron
intake, cancers, bone
RBC (4.5 - 5.9) marrow disorders, chronic
conditions, hemolysis,
hemorrhage) (NHS, 2022)
7.4 8.3 7.4 Low- indicate that the
body isn’t producing
enough RBCs either due
to nutrition deficiency,
Hemoglobin, Male (13.5 - 17.5)
bleeding, other
comorbidities, or genetic
condition (Cleveland
Clinic, 2024)
Hemoglobin, Female (12 - 16) - - -
24.5 26.7 24.7 Low- may be due to blood
loss, bone marrow issues,
Hematocrit, Male (41 - 53) vit/mineral deficiencies or
chronic illnesses
(Cleveland Clinic, 2024)
Hematocrit, Female (36 - 48) - - - -
Platelets (150 - 400) 219 199 - WDL
COAGULATION:
aPTT (24.1 - 36.7) 32.0 - - WDL
INR (0.87 - 1.18) 1.0 - - WDL
Fibrinogen (179 - 395) - - - -
D-Dimer (< 1.6) - - - -
BLOOD GAS & SPECIAL LABS:
pH (7.35 - 7.45) - - - -
PaCO2 (35 - 45) - - - -
PaO2 (80 - 100) - - - -
HCO3 (22 - 26) - - - -
Ionized Calcium (1.2 - 1.32) - - - -
Lactic Acid (< 2.0) - - - -
MISCELLANEOUS:
C-Reactive Protein (0.1 - 0.8) - - - -
B-Natriuretic Peptide (< 100) - - - -
Ammonia (2-30) - - - -
Hemoglobin A1c (3.9 - 5.6) - - - -
Troponin I (< .04ng/mL) - - - -
Lactate Dehydrogenase (90 - 200) - - - -
Myoglobin, Male (17 - 106) - - - -
Myoglobin, Female (14 - 66) - - - -
Creatine Kinase (65 - 210) - - - -
URINALYSIS:
Color (Yellow) - - - -
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Clarity (Clear - Slightly Turbid) - - - -
pH (4.8 - 7.8) - - - -
Specific Gravity (1.005 - 1.030) - - - -
Occult Blood (0) - - - -

Ketones (0) - - - -
Glucose (0) - - - -
Protein (0 – Trace) - - - -
Leukocyte Esterase (0) - - - -
Culture(s), type of culture(s), & results:
- Plasma: Ferritin: 90 ng/mL - WDL
- Plasma: B12: 459 pg/mL - WDL
- Plasma: Folate: 13.7 ng/mL - WDL

Recent Imaging/Diagnostics (XR, CT, US, MRI, Echo, etc.) & results:
- CT: Angio Abdomen & Pelvis
Findings:
- mild bronchiectasis bilaterally
- left renal cysts
- stomach mildly distended with air-fluid level
- stool & gas in colon
- colonic diverticulosis without diverticulitis
- extensive rectosigmoid colonic diverticulosis
Impression:
- no solid organ abdominal masses
- no intestinal obstruction
- no appendicitis or diverticulitis
- not active contrast extravasation within the bowel
- CTA shows no significant narrowing of the visceral and renal arteries

Concept Map: Develop a concept map specific to your patient and include the following key components:

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 NRS 426 Care for Adults with Complex Illness or Injury
Person/Family Centered Clinical Paperwork

First Nursing Priority with rationale

Hypovolemic shock related to rectal bleeding as evidenced by BRBPR, blood-tinged stool, decreased HGB, HCT, &
RBCs.

Harding, M. M. (2023). Lewis's Medical‐surgical nursing: Assessment and management of

clinical problems. (12th ed.) St. Louis, MO: Elsevier

Second Nursing Priority with rationale

Organ failure related to infective tissue perfusion as evidenced by hematochezia, decreased HGB, HCT, & RBCs.

Harding, M. M. (2023). Lewis's Medical‐surgical nursing: Assessment and management of

clinical problems. (12th ed.) St. Louis, MO: Elsevier

Third Nursing Priority with rationale

Risk for anemia as evidenced by BRBPR, blood-tinged stool, decreased HGB, HCT, & RBCs.

Reyes López, A., Gómez Camacho, F., Gálvez Calderón, C., & Miño Fugarolas, G. (1999). Iron-deficiency anemia due
to chronic gastrointestinal bleeding. Revista espanola de enfermedades digestivas, 91(5), 345–358.

Nursing Priority 1
Nursing Priority #1 : Hypovolemic shock Evaluation of SMART goal:
Patient oriented SMART Goal for Nursing Priority 1
Goal was met patient maintained adequate tissue perfusion
Patient will maintain adequate tissue perfusion by throughout shift
maintaining strong peripheral pulses, heart rate within 60-
100 BPM, urinary output of 30ml/hr, and normal LOC
indicating adequate cardiac output.

Assessments (What you would assess and monitor with rationale):

- Assess patients rate and rhythm of heart→ r/o tachycardia
- Skin Assessment
- Capillary refill
- LOC/ mental status
- Respiratory Assessment
- Assess blood pressure
- Assess peripheral pulses
- Monitor I & Os
- Lab values

Nursing Interventions: (Specific to Patient) with rationale Evaluation of Patient Response to Nursing Interventions
• Pre-clinical: How will you evaluate the • Post-clinical: There should be a patient response to
effectiveness of your intervention. (expected the intervention performed. (actual outcome)
outcome)

Intervention 1: (Harding, 2023) Pre-clinical

- Increased blood pressure

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Administer fluid and blood with fluid replacement - Decreased HR if tachycardic
therapy. - Assess vitals: BPs, fluid I& O, CBCs
- Stabilization of patient (HGB&HCT)
- Fluid replacement for loss
Post-clinical
- Patient was administered blood products on day of
admission
- Patient was stable throughout shift
- Pt places on NPO status for GI prep
Intervention 2: (Harding, 2023) Pre-clinical
Place Pt on EKG/ECG monitoring for dysrhythmias. - Electrolytes monitored/ corrected (Cl)
- Indicating low perfusion or hypoxia - No new dysrhythmias
- Rhythm remains stable
- No signs of hypoxia no changes in ekg monitoring
ST segment
Post-clinical
- No outcome regarding EKG
- Inquired with primary RN about reasoning Pt was
not on EKG. RN stated that on admission in ED Pt
may have been placed but had been cleared = no
longer needed EKG monitoring
Intervention 3: (Harding, 2023) Pre-clinical
Monitor 𝑂2 saturation and ABGs - ABGs normal/ WDL
- Progression of hypovolemic shock increased - No increased RR/ WOB
levels of 𝐶𝑂2 and decreasing pH occurs - Oxygen saturation on RA is >92%

Post-clinical
- Monitor 𝑂2 saturation throughout shift Pt
𝑂2 remained above 95% throughout shift
- No ABGs placed or ordered to assess Pts levels

Nursing Priority 2
Nursing Priority #2: Organ Failure Evaluation of SMART goal:
Patient oriented SMART Goal for Nursing Priority 2 (Met/ Partial Met/ Not Met) with Analysis. If goal partial
met or not met put why it was not met and what you plan
Patient will maintain MAP ≥ 65 mmHg and urine output ≥ to do.
30 mL/hr over the next 8 hours as a sign of adequate organ
perfusion. Goal not Pt demonstrated no signs of organ failure
throughout shift such as tachypnea, hypotension, or altered
Patient will demonstrate no signs of organ failure (such as mental status.
tachypnea, hypotension, or altered mental status) by end of Pt had decreased urine output prior to endoscopy
shift. procedure outputting 600ml from 7am -3pm. Indicating
possible renal malfunction may be d/t NPO status.

Assessments (What you would assess and monitor with rationale):

- LOC or new confusion
- Urine output
- BP & HR
- SpO₂ or labored breathing
- Monitor labs for creatinine, AST/ALT, lactate

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- Assess for hypoperfusion

Nursing Interventions: (Specific to Patient) with rationale Evaluation of Patient Response to Nursing Interventions
• Pre-clinical: How will you evaluate the • Post-clinical: There should be a patient response to
effectiveness of your intervention. (expected the intervention performed. (actual outcome)
outcome)

Intervention 1: Prepare for Surgery or colonoscopy (Chen, Pre-clinical

2011) - Ensure that GI tract is clear and not obscured of
- If the patient’s condition worsens, prepare for fecal matter when colonoscopy is done
interventions to address the bleeding source (e.g., - Locate the origin of the bleed
endoscopic hemostasis, surgery) - Ensure and see changes in color of blood from BM

Post-clinical
- Patient reported clear liquid BM
- Patient sent to GI procedure to find location of GI
bleed
- In GI procedure bowels were clear and no sign /
indication of bleeding
- Provider recommendation to perform endoscopy
Intervention 2: Monitor and support renal function. Pre-clinical
(Harding, 2023) - Check BUN, creatinine, and urine output to detect
- Early detection of organ dysfunction through this early signs of kidney failure.
assessment and labs - If urine output falls below 30 mL/hr, notify the
provider for possible renal support (e.g., diuretics,
renal replacement therapy).
Post-clinical
- Did not notify provider of decreased output for
shift.
- Considerable factors for 600 ml output throughout
shift is Pt NPO status and Golytely GI prep
protocol resulting in dehydration
Intervention 3: Monitor Mental Status (Harding, 2023) Pre-clinical
- Determine adequate cerebral perfusion - Watch for changes in mental status (confusion,
lethargy), which can indicate poor cerebral
perfusion.
- Glasgow Coma Scale: indicate stable, improving,
or declining
Post-clinical
- Patient maintained adequate cerebral perfusion
mental status was intact
- Built patient rapport discussing topics of patients
life, family Hx, and first meal in mind once off
NPO status and out of hospital

Nursing Priority 3

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Nursing Priority #3: Anemia Evaluation of SMART goal:
Patient oriented SMART Goal for Nursing Priority 3 (Met/ Partial Met/ Not Met) with Analysis. If goal partial
met or not met put why it was not met and what you plan
Hemoglobin and hematocrit will be monitored q12h to do.
and show stable or improving trends.

Assessments (What you would assess and monitor with rationale):

- Assess for S/Sx of anemia: fatigue/ dizziness/hypotension/ tachycardia/SOB/ pale or cool skin
- Assess status of GI bleed (origin via endoscopy)
- Assess nutritional deficiencies
- Monitor Hgb & Hct
- Assess heart and lungs (related dyspnea, tachypnea, tachycardia, and hypoxia)
- Assess capillary refill/ pulses
- Assess for numbness and pain in lower extremities
Nursing Interventions: (Specific to Patient) with rationale Evaluation of Patient Response to Nursing Interventions
• Pre-clinical: How will you evaluate the • Post-clinical: There should be a patient response
effectiveness of your intervention. (expected to the intervention performed. (actual outcome)
outcome)

Intervention 1: (Chen, 2011) Pre-clinical

Manage cause of blood loss (GI bleed) - Colonoscopy results locate source of GI bleed

Post-clinical
- No location of origin for blood loss
- Follow-up care with GI clinic for endoscopy
Intervention 2: (Harding, 2023) Pre-clinical
Administer replacement fluids (Lactated Ringers) - Administration of ferrous sulfate to correct iron
levels
- Trending increase Hgb & Hct demonstrating
improvement
- Increase in RBCs in labs
Post-clinical
- No changes in trends for blood levels.
- Pt compliant with ferrous sulfate medication
review of labs would be recommended. Second
blood draw occurred after clinical
Intervention 3: (Harding, 2023) Pre-clinical
No signs of tachycardia, arrhythmias, or heart failure - Monitor for absence of chest pain, shortness of
symptoms suggest that anemia is not leading to severe breath, or arrhythmias.
complications. - Regular cardiac monitoring if there are concerns
for tachycardia or arrhythmias due to anemia.
Post-clinical
- Patient displayed no signs of tachycardia,
arrhythmias, or heart failure indicating no signs of
developing complications.

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Medications: Complte all 6 columns for all active medications scheduled and any PRNs given in the last 24 hours and during care. Complete the evaluation of
effectiveness column after medication has been administered.
Medication Medication Class/ Why is YOUR Nursing Implications Adverse Effects Patient Evaluation of
Pharmacokinetics patient taking this Education Effectiveness
medication? and Timing of
Assessment
List generic and trade names, Include: onset, What is the What will you assess List three top What will you Assess
dosage, route and time due peak, duration, rationale for PRIOR to giving this adverse effects of tell your patient effectiveness of
organ of administering? medication? When this medication when you medication
metabolism and would you HOLD administer this administration.
elimination (lab values, allergies, medication?
vital signs/values, *To be filled out
etc.)? List three after medication
patient teaching administration
points.

Golyte Pwdr, Renst-oral Class: Laxative Bowel • Monitor Electrolyte • Nausea • Advise the
Colon Electrolyte Lavage PWD for (Electrolyte preparation for Levels: Renst • Vomiting patient to take
soln Solution) diagnostic contains sodium, • Abdominal the medication
Half gallon • Absorption: GI procedures such potassium, and other cramps with or without
works by drawing electrolytes, so • Diarrhea food, as it does
as a
water into the monitoring for • Electrolyte not affect
intestines, which
colonoscopy. electrolyte imbalances (e.g., absorption.
results in disturbances is hypokalemia, • Instruct the
increased bowel crucial, especially in hyponatremia) patient to report
movements. patients with renal or • Dehydration any signs of
• Onset: Typically cardiac conditions. liver damage
within 1–3 hours • Ensure the patient is (e.g., jaundice,
after ingestion. adequately hydrated dark urine).
• Half-life: Since before, during, and • Explain the
it’s not absorbed, after treatment to importance of
it does not have a avoid dehydration, adherence to
measurable half- especially with large therapy to
life. volumes of fluid loss. avoid HIV
resistance.
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Medication Medication Class/ Why is YOUR Nursing Implications Adverse Effects Patient Evaluation of
Pharmacokinetics patient taking this Education Effectiveness
medication? and Timing of
Assessment

Olopatadine 0.1% Soln, OPH- Class: • Used to treat • Assess for symptoms • Eye irritation or Instruct the
1 drop BID Antihistamine allergic of allergic stinging patient to avoid
(H1-receptor conjunctivitis conjunctivitis. • Headache touching the
antagonist) (itching, redness) • Monitor for adverse • Dry eyes dropper tip to
• Absorption: due to seasonal reactions like eye their eye or any
Rapidly absorbed allergies or other irritation or stinging. surface to
through the allergens. • Ensure the patient is prevent
conjunctiva. using the correct contamination.
• Peak effect: technique to avoid • Advise the
Takes about 1-2 contamination of the patient to
hours for dropper. remove contact
maximum relief. lenses before
• Half-life: administering
Approximately 8- drops and wait
12 hours. at least 15
minutes before
reinserting
them.
• Instruct to
avoid using
other eye
medications
without
consulting a
healthcare
provider.

16
 NRS 426 Care for Adults with Complex Illness or Injury
Person/Family Centered Clinical Paperwork
Medication Medication Class/ Why is YOUR Nursing Implications Adverse Effects Patient Evaluation of
Pharmacokinetics patient taking this Education Effectiveness
medication? and Timing of
Assessment
Simethicone Tab, Chewable Gastrointestinal Abdominal Monitor for Loose stools
80mg, Chew Tab- 160 mg BID agent, onset 30 discomfort due allergic/anaphylactic Dry mouth
minutes, peak to gas reaction. Chills
action 1-2 hours, Take after meals and
duration 3-4 at bedtime for best
hours, results. This
eliminated in medication is
feces available in several
different forms for
ease of use. Stop
taking medication
and contact your
doctor if you
develop an allergic
reaction.
Polyethylene Glycol 17gm/pkt Med class: Constipation Assess ability to Diarrhea, 1. Do not use Patient should
pwdr – QAM Oral Laxative, swallow, abdominal flatulence, this for more have a bowel
osmotic distention nausea than 1 week movement
Onset: 24-96 Hold if indication of 2. Let us know within 96 hrs.
ASAP if you
hours abdominal cramps,
have rectal
Peak: None bowel block, rectal bleeding
Duration: None bleeding 3. Do not use
Metabolism: Teaching: any other
None laxatives or
Elimination: stool softeners
fecal while on this
medication
Albuterol Inhl, Oral Class: Reason for Assessments before -Chest Pain - 3 Teaching
2 puffs – RT Q4H PRN Anticholinergic Administration: giving medication: Palpitations - Points: -Rinse
Onset: 5-15 min. To open airways Assess lungs mouth out
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 NRS 426 Care for Adults with Complex Illness or Injury
Person/Family Centered Clinical Paperwork
Medication Medication Class/ Why is YOUR Nursing Implications Adverse Effects Patient Evaluation of
Pharmacokinetics patient taking this Education Effectiveness
medication? and Timing of
Assessment
Peak: 60-90 min. and increase gas sounds, pulse, BP, Nervousness - after utilizing
Duration: 3-6 hr. exchange that is and secretion Bronchospasm a nebulizer. -
Organ of impaired due to characteristics. Do not double
Metabolism and bronchospasm Monitor pulmonary dose if taken
Elimination: function tests before at home. -
Small amounts initiating therapy. Chew gum to
absorbed and Observe for reduce dry
metabolized in paradoxical mouth.
the liver. bronchospasm
(wheezing). 3
Teaching Points: -
Rinse mouth out
after utilizing a
nebulizer. -Do not
double dose if taken
at home. -Chew
gum to reduce dry
mouth.
Bisacodyl enteric coated tab, EC Class: Laxative, Used to treat Prior: assess for last Diarrhea, 1. Inform pt
15 mg PO stimulant constipation BM. Assess GI and flatulence, not to take
Onset: 6-12hr abd. Check for bowl abdominal pain med with milk
Peak: unknown sounds (full 5 min if or dairy
Duration: no noise per quad). products 1
unknown Hold for diarrhea, hour after
Metabolism: successful BM, or ingestion as it
liver, GI allergy to aniline can cause
Elimination: GI dye or rapid
diphenylmethane breakdown of
laxative EC coating 2.
Medication
18
 NRS 426 Care for Adults with Complex Illness or Injury
Person/Family Centered Clinical Paperwork
Medication Medication Class/ Why is YOUR Nursing Implications Adverse Effects Patient Evaluation of
Pharmacokinetics patient taking this Education Effectiveness
medication? and Timing of
Assessment
may cause
diarrhea so
plan
accordingly 3.
Do not crush
or chew tablet
Mometasone HFA 200mcg inhl, Class: • Used to prevent • Monitor lung • Oral candidiasis • Instruct the
oral Corticosteroid asthma attacks function, particularly (thrush) patient to rinse
2 puffs, oral inhalation (Inhaled) and chronic peak flow, to assess • Sore throat their mouth
• Absorption: obstructive effectiveness. • Hoarseness after each use
Rapidly absorbed pulmonary • Educate the patient to prevent oral
after inhalation, disease (COPD) on the proper use of fungal
but most of the flare-ups. the inhaler to ensure infections.
drug is retained in the medication • Advise the
the lungs. reaches the lungs. patient to use
• Metabolism: • Monitor for signs of the inhaler
Hepatic infection (e.g., oral regularly, even
(metabolized by candidiasis). when
the liver). • Use with caution in asymptomatic,
• Half-life: patients with a history to control
Approximately of tuberculosis or asthma.
5.8 hours. fungal infections. • Teach the
correct
inhalation
technique to
ensure
maximum
benefit.

Allopurinol Tab Antigout agent; Patient is taking Prior to giving this DRESS This
100mcg, PO xanthine oxidase this medication medication assess syndrome medication is
inhibitor for the patient for rash and Stevens-Johnson used to
19
 NRS 426 Care for Adults with Complex Illness or Injury
Person/Family Centered Clinical Paperwork
Medication Medication Class/ Why is YOUR Nursing Implications Adverse Effects Patient Evaluation of
Pharmacokinetics patient taking this Education Effectiveness
medication? and Timing of
Assessment
Onset: 1-2 days prevention of assess patient’s Syndrome prevent gout.
Peak: 1-2 wk gout. Patients renal function. Hold Hypersensitivity Stop this
Duration: 1-3 with type 2 if there is a rash reactions medication
wk diabetes have because it is a sign immediately if
Metabolized and high levels of of Stevens-Johnson there is a
eliminated by uric acid in their Syndrome and if development
the liver. blood which creatinine clearance of a rash. Do
may be due is less than 30 not drink large
from extra fat. mL/min. amounts of
Kidneys have a This medication is alcohol while
harder time used to prevent on this
getting rid of gout. Stop this medication
uric acid which medication because it will
may lead to immediately if there negate the
gout. is a development of effects of the
a rash. Do not drink Allopurinol.
large amounts of
alcohol while on
this medication
because it will
negate the effects of
the Allopurinol.
Darunavir Ethanolate Tab Class: • Used in the • Assess for liver • Diarrhea • Instruct the
800 mg, PO Antiretroviral treatment of function before and • Rash patient to take
(Protease HIV-1 during therapy. • Hepatotoxicity the medication
Inhibitor) infection, • Monitor for signs of with food to
• Absorption: allergic reactions, enhance
usually as part
Well absorbed in including rash or absorption.
the
of combination swelling. • Advise the
gastrointestinal therapy. patient to report

20
 NRS 426 Care for Adults with Complex Illness or Injury
Person/Family Centered Clinical Paperwork
Medication Medication Class/ Why is YOUR Nursing Implications Adverse Effects Patient Evaluation of
Pharmacokinetics patient taking this Education Effectiveness
medication? and Timing of
Assessment
tract when taken • Check for potential any skin rashes
with food. drug interactions, as or signs of liver
• Metabolism: darunavir is dysfunction
Hepatic (primarily metabolized by (e.g., yellowing
metabolized by cytochrome P450. of the skin or
the liver via • Encourage eyes).
cytochrome P450 adherence to the • Stress the
enzymes). medication regimen to importance of
• Half-life: 15 prevent resistance. adherence to
hours. the prescribed
regimen to
prevent HIV
progression.

Emtricitabine/Rilpivirine/Tenofovir Class: • Used as part of • Assess for signs of • Nausea • Take the
25 mg tab, 1 tablet, PO Antiretroviral combination hepatotoxicity and • Diarrhea medication
(NRTI and therapy for the kidney function • Headache with food to
NNRTI treatment of HIV- before and during improve
combination) 1 infection. treatment. absorption.
• Absorption: Well • Monitor for adverse • Advise the
absorbed with a gastrointestinal patient to report
high-fat meal. effects, particularly any signs of
• Metabolism: nausea. liver or kidney
Hepatic, via • Educate the patient dysfunction.
cytochrome P450 on proper adherence • Encourage
enzymes. to prevent resistance. strict adherence
• Half-life: to the
Emtricitabine (10 prescribed
hours), Rilpivirine regimen to
(45 hours), avoid drug
Tenofovir (17 resistance.
hours).

21
 NRS 426 Care for Adults with Complex Illness or Injury
Person/Family Centered Clinical Paperwork
Medication Medication Class/ Why is YOUR Nursing Implications Adverse Effects Patient Evaluation of
Pharmacokinetics patient taking this Education Effectiveness
medication? and Timing of
Assessment

Ezetimibe Tab 10mg, PO Class: Patient has a hx HOLD for Rash 1. Take as
cholesterol of HLD hypersensitivity and Cholecystitis directed at the
absorption moderate or severe Myopathy same time each
inhibitors hepatic impairment Rhabdomyolysis day
2. Medication
Onset: unknown Assess diet hx and Angioedema
should be used
Peak: unknown cholesterol and in conjunction
Duration: triglyceride levels with diet
unknown before initiating, restrictions
Metabolism: after 2-4 wk of 3. Notify health
enterohepatic therapy care
recycling professional if
Excretion: feces HMG-CoA unexplained
reductase inhibitors muscle pain,
tenderness, or
weakness
occur. Risk
may increase
when used with
Ferrous Sulfate Med class: Iron Anemia (low Assess ability to Fever, black 1. Please keep
325mg, PO preparations iron levels)- swallow. Administer tarry stools, this
Onset: ~3-10 nutritional with juice or on an vomiting blood medication
days support empty stomach or throw-up that out of reach of
Peak: 5-10 days Hold if any looks like coffee children when
Duration: n/a indication of GI grounds, you get home.
Metabolism: disease- peptic constipation, Call poison
duodenum and ulcer, enteritis or stomach cramps control right
upper jejunum ulcerative colitis away if you
Elimination: suspect a
urine, sweat, grandchild has

22
 NRS 426 Care for Adults with Complex Illness or Injury
Person/Family Centered Clinical Paperwork
Medication Medication Class/ Why is YOUR Nursing Implications Adverse Effects Patient Evaluation of
Pharmacokinetics patient taking this Education Effectiveness
medication? and Timing of
Assessment
sloughing of taken this
intestinal medication on
mucosa, menses accident 2.
Don’t be
alarmed if
your stools
change color-
can be green
or a black,
tarry
appearance 3.
Please take
this on an
empty
stomach
Fluticasone Propinate Med class: Management of Assess nasal canal Headache, nose Teaching:
50mcg Soln, Nasal, 2 sprays each Corticosteroid seasonal and for patency and or throat 1. Keep using
nostril Onset: ~several perennial intact septum irritation, this drug as
days to several allergic rhinitis Hold if patient has nosebleed prescribed by
months severe stuffy nose, your doctor,
Peak: N/A nasal sores, do not
Duration: N/A nosebleeds, or abruptly stop
Metabolism: abnormal nasal administration
Hepatic discharge 2. Prime the
Elimination: pump per
Fecal medication
instructions
3. Blow your
nose before
use
23
 NRS 426 Care for Adults with Complex Illness or Injury
Person/Family Centered Clinical Paperwork
Medication Medication Class/ Why is YOUR Nursing Implications Adverse Effects Patient Evaluation of
Pharmacokinetics patient taking this Education Effectiveness
medication? and Timing of
Assessment
Losartan tab Class: This medication Prior: assess BP and Diarrhea, back Notify
100mg, PO Angiotensin II is indicated for monitor throughout pain, stuffy nose provider if
Receptor pts with HTN med admin. Check unable to pass
Blocker and for those for signs of urine or there
onset: 1 hr with left angioedema. Verify is a serious
peak: 6 hr ventricular pt is not taking change in the
duration: 24 hr hypertrophy as aliskiren for pts with amount of
organ of it can reduce the DM urine passed
metabolism: risk of stroke. 2. There is a
liver risk of
organ of hypokalemia
elimination: and pt should
renal, fecal alert team for
abnormal
heart beat,
confusion,
weakness 3.
There is the
risk of
syncope and
extreme
dizziness and
pt should be
careful when
standing
Maraviroc tab Class: • Used in • Monitor liver • Hepatotoxicity • Advise the
150mg, PO Antiretroviral combination with function regularly, as • Rash patient to take
(CCR5 other maraviroc can cause • Cough the medication
Antagonist) antiretrovirals for hepatotoxicity. • Abdominal pain with or without
food, as it does

24
 NRS 426 Care for Adults with Complex Illness or Injury
Person/Family Centered Clinical Paperwork
Medication Medication Class/ Why is YOUR Nursing Implications Adverse Effects Patient Evaluation of
Pharmacokinetics patient taking this Education Effectiveness
medication? and Timing of
Assessment
• Absorption: Well the treatment of • Assess for signs of • Orthostatic not affect
absorbed in the HIV-1 infection. systemic allergic hypotension absorption.
gastrointestinal reactions (e.g., rash, • Instruct the
tract. fever, eosinophilia). patient to report
• Metabolism: • Screen for CCR5- any signs of
Hepatic tropic HIV-1 before liver damage
(metabolized by starting therapy. (e.g., jaundice,
cytochrome P450 dark urine).
enzymes). • Explain the
• Half-life: 14–18 importance of
hours. adherence to
therapy to
avoid HIV
resistance.

Ritonavir tab Class: Used as part of Monitor for liver • Diarrhea • Take the
100mg, PO Antiretroviral combination function and any signs • Nausea medication
(Protease therapy for HIV-1 of hepatotoxicity. • Vomiting with food to
Inhibitor) infection. • Liver toxicity reduce
• Absorption: GI • Watch for drug • Hyperlipidemia gastrointestinal
• Metabolism: interactions, as side effects.
Hepatic ritonavir is a potent • Advise the
(metabolized by CYP450 inhibitor. patient to report
cytochrome P450 any signs of
enzymes). • Assess for signs of liver damage.
• Half-life: 3–5 gastrointestinal side • Explain the
hours. effects. importance of
Indication: adherence to
• Used as part of prevent HIV
combination resistance and
therapy for HIV-1 complications.
infection. Often

25
 NRS 426 Care for Adults with Complex Illness or Injury
Person/Family Centered Clinical Paperwork
Medication Medication Class/ Why is YOUR Nursing Implications Adverse Effects Patient Evaluation of
Pharmacokinetics patient taking this Education Effectiveness
medication? and Timing of
Assessment
used as a
pharmacokinetic
booster for other
protease
inhibitors.

26
 NRS 426 Care for Adults with Complex Illness or Injury
Person/Family Centered Clinical Paperwork
Focus Notes & Hand-off Report

Focus Note (after clinical)

Urine Output – Patient voiced when asked if he has used the restroom since returning from the GI clinic procedure
ummm no you know what no I haven’t yet’. Last recorded urine output was prior to GI procedure @11:45 output was
600mL total. Patient given clear liquids per MD order and informed to notify when he has urinated. Pt informed to use
the urinal for output measurement.
04.07.25-–Makaylah Hoang BIMSON nursing student
Hand-off Report (after clinical)
SITUATION (Name, age, date of admission. Primary diagnosis. Major events during hospitalization
(surgeries/procedures). Isolation. Code Status. Primary team/ interdisciplinary teams)

BACKGROUND (Pertinent past medical history/contributing comorbidities. Allergies. Family/social/spiritual

concerns)

ASSESSMENT (VS/Review of systems. Lines/drains. Recently given medications/high alert medications. Significant
labs. Diet. Activity. Safety: fall risk/restraints/holds/etc. Notable events during shift)

RECOMMENDATIONS (Pending procedures. Goals: short term/long term/DC. Education needs. Follow up items
needed)

27
 NRS 426 Care for Adults with Complex Illness or Injury
Person/Family Centered Clinical Paperwork
Reference Page
Chen ZJ, Freeman ML. Management of upper gastrointestinal bleeding emergencies: evidence-based medicine and
practical considerations. World J Emerg Med. 2011;2(1):5-12. doi: 10.5847/wjem.j.1920-8642.2011.01.001.
PMID: 25214975; PMCID: PMC4129733.

Harding, M. M. (2023). Lewis's Medical‐surgical nursing: Assessment and management of

clinical problems. (12th ed.) St. Louis, MO: Elsevier

Hematocrit test: What it is, levels, high & low range. Cleveland Clinic. (2024, May 1).
https://my.clevelandclinic.org/health/diagnostics/17683-hematocrit

Taghavi S, Nassar Ak, Askari R. Hypovolemic Shock. [Updated 2023 Jun 5]. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513297/

Mayo Foundation for Medical Education and Research. (n.d.). Hyperglycemia in diabetes. Mayo Clinic.
https://www.mayoclinic.org/diseases-conditions/hyperglycemia/symptoms-causes/syc-20373631

Nagami, G. T. (2016). Hyperchloremia. Hyperchloremia - an overview | ScienceDirect Topics.

https://www.sciencedirect.com/topics/medicine-and-dentistry/hyperchloremia

NHS. (2022, July 6). Red Blood Cell Count. NHS choices. https://www.nhs.uk/conditions/red-blood-
count/#:~:text=A%20low%20RBC%20count%20could,to%20meet%20their%20body’s%20needs).

Ryan, K. L., Rickards, C. A., Ludwig, D. A., & Convertino, V. A. (2010). Tracking central hypovolemia with ecg in
humans: cautions for the use of heart period variability in patient monitoring. Shock (Augusta, Ga.), 33(6), 583–
589. https://doi.org/10.1097/SHK.0b013e3181cd8cbe

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