Adulthealth-2CarePlan.doc - Howard Assignments

PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

Student Name:

Week: 6

Dates of Care:05/20/23

Patient Initials

F A

Sex

Age

Room

804

Admitting Date

05/19/23

Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

Fatigue and general weakness and experiencing pain in the lower back. The patient was brought by his son because he was too weak to get out of bed.

Attending physician/Treatment team:

Ayman M Jabr

Consults:

Present Diagnosis: (Why patient is currently in the hospital)

Acute Pyelonephritis

ER Management: (if applicable)

Allergies:

No allergies

Code Status:

Full code

Isolation: (type and reason)

Admission Height:

5’6 inches

Admission Weight:

62kg (136 Ib 11 oz)

Arm Band Location (colors & reasons)

Communication needs: (verbal, nonverbal, barriers, languages)

Patient speak Spanish only and

Past Medical History: (pertinent & how managed)

Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)

Tests/Treatments/Interventions impacting clinical day’s care (include current orders)

Assessments and interventions: (Include all pertinent data)

Vital signs: (2 sets per day)

Time

05/20/23 0735

99.2 F(37.3C)

B/P

132/78

Time

05/21/23 0755

98.6

B/P

GI:

Diet:

Swallow precautions:

Tube feedings:

NG / G tube:

Blood Glucose: (time & date)

Last bowel movement: (time & date)

Pertinent Labs/Test:

Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)

Respiratory:

02 modalities:

02 Saturation:

Suction:

Resp Rx’s:

Trach:

Chest Tubes:

Pertinent Labs/Test:

Assessments/Interventions: (Lung sounds, cough, sputum, SOB)

Neurosensory:

Neuro checks:

Alert & Orientated:

Follows commands:

Speech Comprehensible:

Pertinent Labs/Test:

Assessments/Interventions:

(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)

Cardiovascular:

Telemetry:

Pacemaker/IAD:

DVT Prevention:

Daily Weights:

Pertinent Labs/Test:

Assessments/Interventions:

(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)

Musculoskeletal:

Activity:

Traction:

Casts/Slings:

Pertinent Labs/Test:

Assessments/Interventions:

(strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps

Renal:

Catheter (indwelling/external):

CBI:

Dialysis:

A/V access:

Pertinent Labs/Test:

Assessments/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O)

Skin:

Braden Score:

Pertinent Labs/Test:

Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)

Pain:

Pain score:

Assessments/Interventions:

(scale used, location, duration, intensity, character, exacerbation, relief, interventions)

Vascular Access: (IV site)

Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)

Gyn:

Gravida/Para:

LMP:

Last Pap:

Breast exam:

Pertinent Labs/Test

Assessment/Interventions: (bleeding, discharge)

Post-operative /procedural:

Assessments/Interventions:

(immediate post procedure care)

Safety:

Call light:

Bed Rails:

Bed alarms:

Fall risk:

Assistive Devices:

Sitter use:

Restraints (type, duration & reason):

Assessment/Interventions (modifications to room, environment, Patient)

Advance Directives/Ethical considerations:

DPOA:

Hospice:

Pertinent Data (Labs, X-rays, Etc.)

Results

Normal Lab Values

Significance to your patient

WBC

11.5

4.0-11.k/mm

RBC

3.55

3.6-5.04

HGB

11.5

HCT

MCV

90.3

MCH

29.3

MCHC

32.5

Platelets

260

RDW

15.9

MPV

8.3

INR

APTT

Glucose

BUN

Creatinine

1.0

Sodium

3.5

Potassium

3.8

Cloride

1.08

Calcium

7.7

T Protein

6.1

Albumin

3.4

SGOT

SGPT

Alk Phos

Magnesium

1.6

Amylase

Lipase

CPK

LDH

Cholestrol

105

CK-MB

Troponin I

Myoglobin

LDI

Urinalysis

Color

Character

Spec. Grav.

Protein

Glucose

Acetone

Bilirubin

Blood

Nitr

Urobili

RBC

WBC

Epithelium

Urine Culture

Chest X-ray

MRI

CT Scan

Others test:

Psycho/Social: Assessment/Interventions:(mental illness, social history, living arrangements, primary care giver, substance abuse, maternal/infant bonding, family dynamics)

Cultural/Spiritual needs: Assessment/Interventions: (religious preference, adaptations & modifications, end of life decisions)

Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient:

Current overall plan of care: (A short statement that summarizes the anticipated plan of care)

Discharge plans and needs:

Teaching needs:(Disease process, medications, safety, style, barriers)

Pathophysiological Discussion: Discuss the current disease process at the cellular level (in your own words). Explain why this patient is encountering this particular health deficit. What is the relationship of this current health alteration to the patient’s other medical conditions? Describe the current disease process the patient is encountering etiology, epidemiology, pathophysical mechanism, manifestations and treatment (medical and surgical). Also note the complications that may occur with these treatments and the patient’s overall prognosis. Include appropriate references and use APA format.

Attach a research article pertaining to diagnosis of patient. Write a summary about the article.

List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting. May only list one nursing diagnosis that is a Risk For diagnosis.

Priority	Nursing Diagnosis	Related to	As Evidence By	Rationale (reason for priority)
1	Acute Pain	Inflammation and infection of the urinary tact	Report of pain/ burning discomfort when urinating	The patient experienced severe pain during urination.
2	Hyperthermia	Inflammation process secondary to pyelonephritis	Increasing body temperature above the normal range	The patient always has fever symptoms
3	Impaired Urinary elimination	Kidney infection and inflammation	Urinary retention	The patient experienced frequency and hesitancy urine
4
5

Medications

Classification

Dose

Route

Freq

Purpose/Mechanism of Action

Significant Side Effects / Adverse Reactions

Nursing Implications

Lipitor

Atorvastatin

40mg

oral

daily

Inhibits HMG -COA retake enzyme which reduces cholesterol synthesis high dose lead to plaque regression

Feeling sick (nausea), Headaches, diarrhea, runny nose, sore throat, constipation

Rocephin

Ceftriaxone

oral

daily

Inhibits cell wall biosynthesis by

Black tarry stool. Chest pain, shortness of breath. Sore throat, Swollen glands, and weakness

Plavix

Clopidogrel

75mg

oral

daily

Headaches, dizziness Nausea, Diarrhea, constipation, nosebleeds

Vasotec

Enalapril

10mg

oral

Daily

Blurred vision itching or mild rash, diarrhea, Headaches

Tylenol

Heparin

Acetaminophen

650mg

oral

6 hours

Red, peeling or blistering skin, rash , hives, itching, and difficulty breathing

Nursing Diagnosis: Identify the top two nursing Diagnoses and expand

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)

Patient Goal(s)

Statement of purpose for the patient to achieve

Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)

(Must have at least two short term outcomes and two long term outcomes)

Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.

Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)

Nursing Diagnosis: Identify the top two nursing Diagnoses and expand

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)

Patient Goal(s)

Statement of purpose for the patient to achieve

Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)

(Must have at least two short term outcomes and two long term outcomes)

Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.

Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)

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