Assignments 2
ATIENT/CLIENT DATA - CLINICAL DECISION-MAKING WORKSHEET
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Student Name: |
Week: |
Dates of Care: |
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Patient Initials
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Sex M |
Age
58 |
Room |
Admitting Date |
Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?
Positive for MRSA, Patient presents with fever, malaise/fatigue, dizziness, altered mental status, pneumonia, R shoulder pain. (these are the nursing diagnosis) |
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Attending physician/Treatment team:
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Consults: |
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Present Diagnosis: (Why patient is currently in the hospital)
Positive for MRSA bacteremia
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ER Management: (if applicable)
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Allergies:
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Code Status: |
Isolation: (type and reason)
Contact Precaution MRSA |
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Admission Height:
5’8 |
Admission Weight:
168.6 lbs |
Arm Band Location (colors & reasons)
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Communication needs: (verbal, nonverbal, barriers, languages) (Osborn pages 258 - 262)
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Past Medical History: (pertinent & how managed)(Osborn Chapter 9)
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Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)
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Tests/Treatments/Interventions impacting clinical day’s care (include current orders)
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Psycho/Social: Assessment/Interventions:(mental illness, social history, living arrangements, primary care giver, substance abuse, maternal/infant bonding, family dynamics)
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Cultural/Spiritual needs: Assessment/Interventions: (religious preference, adaptations & modifications, end of life decisions) (Osborn Chapter 9) |
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Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorist) (Osborn Chapter 13) What stage of development evident with patient:
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Current overall plan of care: (A short statement that summarizes the anticipated plan of care)
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Discharge plans and needs:
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Teaching needs:(Disease process, medications, safety, style, barriers)
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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.
CDH II: 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.
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Priority |
Nursing Diagnosis |
Related to |
As Evidence By |
Rationale (reason for priority) |
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1 |
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2 |
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3 |
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4 |
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5 |
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6 |
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7 |
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8 |
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9 |
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10 |
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Medications |
Classification |
Dose |
Route |
Freq |
Purpose/Mechanism of Action |
Significant Side Effects / Adverse Reactions |
Nursing Implications |
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Acetaminophen (TYLENOL) tablet
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650 mg |
PO |
Once daily |
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Amiodarone (PACERONE) tablet
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200 mg |
PO |
Once daily |
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Atorvastatin (LIPITOR) tablet
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10 mg |
PO |
Once a Night |
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Calcium acetate (CALPHRON) tablet
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667 mg |
PO |
3 times daily |
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Ceflaroline (TEFLARO) 400 mg in sodium chloride 0.9% 100 ml IVPB
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400 mg |
IV |
Every 12 hours |
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DAPTOmycin (CUBICIN) 600 mg in sodium chloride 0.9% 50 ml IVPB
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8 mg |
IV |
3 times weekly |
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Epoetin alfa-ephx (RETACRIT) injection 10,000
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10,000 |
SC |
Once per day mon, Wed, and Fri |
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Ergocalciferol (DRISDOL) capsule 50,000 Units
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50,000 Units |
PO |
Weekly |
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Tamsulosin (FLOMAX)
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0.4 mg 1 capsule |
PO |
Daily after dinner |
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Nursing Diagnosis:
Assessment as evident by (AEB) or data collection relative to the nursing diagnosis |
Patient Goal(s) |
Patient Outcome (objective, expected or desired outcomes or evaluation parameters) |
Interventions/Implementations |
Evaluation |
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Guidelines for Nursing Process
Nursing diagnosis consists of the diagnostic label, “related to” and the “as evidence by” components (see below).
Diagnostic label: Is selected from the NANDA International Diagnosis.
Related to: the condition or etiology of the problem the patient is experiencing. Should be in domain of nursing practice that nursing interventions can aggect. Should be the medical diagnosis.
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Assessment as evident by (AEB), or data collection relative to the nursing diagnosis |
Patient Goal(s) |
Outcome (objective, expected or desired outcomes or evaluation parameters |
Interventions/ Implementations |
Evaluation |
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Assessment supports the nursing diagnosis above. The assessment should reflect the “defining characteristics” that are expected to be present for that diagnosis to be appropriately utilized.
Review Chapter 7 in Osborn for the elements of assessment that should be contemplated.
Types of data: subjective & objective Sources of data Nursing health history Physical examination Diagnostic data |
“A statement of purpose describes the aim of nursing care” (Osborn et. al., p. 113)
Refer to Chapter 7 in Osborn for review of nursing diagnosis (may have more than one outcome for each nursing diagnosis) |
May be short or long term assists in the ongoing evaluation of the patient’s progress to achieving the goal.
Should be acceptable by the patient and the nurse, realistic, specific and measurable (Osborn, et al., 2010)
Stated realistic behavioral terms that can be observed, measured and relevant to the identified nursing diagnosis. |
Intervention – the planned nursing actions that are likely to achieve the desired outcomes (Osborn, et al., 2010).
Implementation – the carrying out of the planned nursing interventions (Osborn, et al., 2010)
Interventions should reflect on going assessment and activities that will assist in achieving the goal/outcomes.
Interventions should reflect indendent nursing practice as well as collaborative practice.
Interventions should reflect the needs of this specific patient not a generic listing of possible interventions. Interventions should include specific like schedules, food choices, frequency, etc….
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Focuses on change and compares the changes with the outcomes (Osborn et al., 2010).
Essentially this is a reassessment of the patient and the responses as to the interventions implemented.
Compare actual patient behaviors with expected behaviors.
Give reasons why or why not each outcome has been met.
Consider the effectiveness of the nursing intervention, time elements. |