Amanda, Davies

Amanda Davies

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PATIENT/CLIENT DATA - CLINICAL DECISION-MAKING WORKSHEET

Student Name:

Week: 5

Dates of Care:

Patient Initials

C.C

Sex

Age

Room

Admitting Date

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

Shortness of breath, cough and body aches.

Attending physician/Treatment team:

Consults:

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

Sepsis, Acute hypoxemia respiratory failure, Severe Pneumonia with innumerable cavity lesions. Left Side Pneumothorax.

ER Management: (if applicable)

Allergies:

N/A

Code Status:

FULL

Isolation: (type and reason)

N/A

Admission Height:

1.575m (5’2”)

Admission Weight:

78 kg (171 lbs. 15.3oz)

Arm Band Location (colors & reasons)

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

None

Past Medical History: (pertinent & how managed)

History of IVDU, heroin, cocaine. Chronic IV heroine, denies ever being in a treatment program.

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

1) Chest X-ray: 9/2/21- extensive consolidations with some possible cavitary lesions in the upper lobes.

· Repeat CXR: 9/13/21- Worsening bilateral alveolar infiltrates and right pleural effusion. Question of a small loculated pneumothorax near 5the left costophrenic angle.

· Repeat CXR: 9/22/2021- Diffuse pulmonary parenchymal infiltrative changes.

· Repeat CXR: 09/24/2021- Small left lower lobe pneumothorax with pigtail drainage catheter are unchanged in position.

2) CTA Chest: 9/2/21- Severe Pneumonia, no cavity lesions, neg for PE.

Repeat CT chest: 9/9/21- Extensive reticular nodular lung disease with coalescent

Repeat CT chest: 9/16/21- neg for PE, new left loculated anterior inferior collection of gas may be due to; loculated left sided pneumothorax with bronchopleural fistula.

3) CT Surgery, Left sided chest tube placement, 09/22/2021. CT guided lung biopsy performed 09/22/2021.

4) MRI: lumbar spine and brain ordered to r/o abscess- awaiting results

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

· Positive for fentanyl, cocaine, methadone: 3-day methadone taper, COWS protocol.

· BLE swelling and LLE pain, RUE swelling- neg for e/o DVT or superficial phlebitis.

· Hygperkalemia- Resolved (Monitor BMP daily)

Assessments and interventions: (Include all pertinent data)

Vital signs: (2 sets per day)

Time

B/P

Time

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

13.7

RBC

2.90

HGB

8.2

HCT

21.7

MCV

87.4

MCH

MCHC

Platelets

178

RDW

MPV

INR

APTT

Glucose

BUN

Creatinine

0.96

Sodium

131

Potassium

5.1

Chloride

105

Calcium

7.7

T Protein

Albumin

1.8

SGOT

SGPT

Alk Phos

Magnesium

Amylase

Lipase

CPK

LDH

474

Cholestrol

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.

ADH 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. 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
2
3
4
5

Medications	Classification	Dose	Route	Freq	Purpose/Mechanism of Action	Significant Side Effects / Adverse Reactions	Nursing Implications
Acetaminophen
Albumin Human 25% infusion
Carvediol (COREG) tablets
ceFAZolin (ANCEF) 2g in sodium chloride 0.9% 100ml IVPB
Clindamycin in dextrose 5% (CLEOCIN) IVPB Furosemide (LASIX) Injection
GuaiFENsin-codeine
HYDROcodone-acetaminophen
Lidocaine (ASPERCREME)
Nicotine (NICODERM CQ) Nystatin (MYCOSTATIN)

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)

PAGE

Amanda, Davies

Medications

Classification

Dose

Route

Purpose/Mechanism of Action

Significant Side Effects / Adverse Reactions

Nursing Implications

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)

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

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)

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)

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

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)