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PATIENT/CLIENT DATA - CLINICAL DECISION-MAKING WORKSHEET

Student Name:

Week:

Dates of Care:

Demographics and Brief History

Patient Initials

Sex

Age

Room

15th

Admitting Date

3/23/21

Admitting Chief Complaint: What symptoms cause the patient to come to the hospital? PT comes in for psch evaluation. Admits to SI with plan of choking herself. She tried to overdose on Tylenol about a year ago. Denies HI. Pt has been hearing voices to harm herself for few days. PT has not been taking her medication since 3 months ago states there is a lot of family issues going on.

Attending physician/Treatment team:

Precautions:

Primary Diagnosis: Anxiety, Depression, PSTD (Post traumatic stress disorder), OCD (Obsessive compulsive disorder

Co-morbidities: Delusional

Allergies: No known Allergies

Code Status: Full Code

Isolation: (type and reason)

None

Admission Height:

5.7

Admission Weight:

68kg(150lb)

Arm Band Location (colors & reasons)

Right Arm. For identification and medication administration.

Past Medical History: (pertinent & how managed) Anxiety, Depression, PSTD (Post traumatic stress disorder), OCD (Obsessive compulsive disorder)

Significant Events during this hospitalization but not during this clinical time: (examples include restrictive interventions or any medical emergencies. Include date, event and outcome)

Physical Assessments and Interventions: (Include all pertinent data)

Vital signs:

Time	3/28/21
T	98.7 F
P	90 beat/min
R	18 breath/min
B/P	115/77 mmHg

General Appearance

· Grooming/Clothing

· Hygiene

· Posture

· Gait

· Obese/average or normal/ underweight

· Evidence of scars/ abrasions/ bruises/ tattoos/ or other physical markings

Activities of Daily Living

· Sleep/rest

· Diet

· Exercise/mobility

· Elimination

· Hygiene

Diet:

Blood Glucose (time & date):

Last bowel movement (time & date):

Pertinent Labs/Test:

Assessments:

· Stool

· Bowel sounds

· Tenderness, distention

· Appetite, nausea, vomiting

Interventions:

Respiratory:

Assessments:

· Lung sounds

· Cough, sputum

· SOB

Interventions:

Neurosensory:

Alert & Orientated:

Follows commands:

Speech Comprehensible:

Pertinent Labs/Test:

Assessments:

· LOC

· Pupils

· Glascow Coma Scale

· Dizziness

· Headaches

· Tremors

· Tingling, weakness, paralysis, or numbness

Interventions:

Cardiovascular:

Pertinent Labs/Test:

Assessments

· Peripheral pulses

· Heart sounds (murmurs or bruits)

· Edema

· Chest pain, discomfort, palpitations

Interventions:

Musculoskeletal:

Activity:

Casts/Slings:

Assessments:

· Strength, weakness

· ROM

· Gait (documented under appearance)

· Pain

· Fractures, amputations, or transfers

Interventions:

Renal:

Pertinent Labs/Test:

Assessments:

· Bruit, thrill, location

· Urine-quality

· Burning with urination, hematuria

· Incontinent, continent, I & O

Interventions:

Skin:

Braden Score:

Pertinent Labs/Test:

Assessments

· Bruising, wounds, drains

· Turgor

· Surgical incisions

· Finger & toe nails

Interventions:

Pain:

Pain score:

Assessments/Interventions:

· Scale used

· Location, duration, intensity, character

· Exacerbation, relief

Interventions:

Gyn:

Gravida/Para:

LMP:

Last Pap:

Breast exam:

Pertinent Labs/Test:

Assessment

· Bleeding

· Discharge

Interventions:

Safety:

Bed Rails:

Bed alarms:

Fall risk:

Assistive Devices:

Interventions:

Advance Directives/Ethical considerations:

AD:

POA:

Lab Values	Results	Normal Lab Values	Significance to your patient (if applicable)
WBC	5.7	4.5-11.0	Normal
RBC	4.28	3.63-5.04
HGB	12.3	12.0-15.3
HCT	37.1	34.7-45.1
MCV	86.8	80.0-100.0
MCH	28.7	26.0-34.0	Normal
MCHC	33.1	32.5-35.8
Platelets	Not recorded
RDW	13.1	11.9-15.9	Normal
MPV	8.8	6.8-10.2
Glucose	98	70-99	Normal
BUN	8	7-20	Normal
Creatinine	0.65	0.6-1.2	Normal
Sodium	135	133-144	Normal
Potassium	3.7	3.5-5.2
Cloride	104	98-107
Calcium	Not recorded
Salicylate	Not recorded

Please add lab values for any medications that may require a blood draw (e.g., Lithium, Lamotrigine, Carbamazepine, Oxcarbazepine, Sodium valproate/divalproex sodium)

Lab Value	Results	Normal Lab Values	Significance to your patient (if applicable)

10 Panel Toxicology/Drug Screen: if available

Lab Value	Results	Normal Lab Values	Significance to your patient (if applicable)

Blood Alcohol Level/Ethyl Serum Level: if available

Lab Value

Results

Normal Lab

Values

Significance to your patient (if applicable)

Psycho/Social Assessment

· Level of education

· Not on file

· Occupation

· Not on file

· Race/Ethnic Background or Identification

· Not on file

· Religion/Spiritual Beliefs

· Not on file

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

· Not on file

· Special Talents/Interests/Skills

· Not on file

· Environment (home and community)

· Not on file

· Family Structure/History: No family history on file

Stage of Development: (Erikson’s Stage of Development, describe the current stage of the client and previous stages that the client may not have successfully completed)

Support System:

Stressors/Stress Management Practices:

Pathophysiological Discussion: One scholarly article must be cited using APA format in this section. The textbook may also be used as a secondary source. The reference list should be included with the summary of the article.

Discuss the current disease process:

Discuss the etiology of the patient’s illness:

Also note the complications that may occur with treatments and patient’s overall prognosis:

Attach a research article pertaining to diagnosis of patient. Write a summary about the article below and include a reference list:

References

Medications	Classification	Dose	Route	Freq	Purpose/Mechanism of Action	Significant Side Effects / Adverse Reactions	Nursing Implications
Lorazepam		1mg	oral	PRN Q6r	Management of anxiety and irritability disorder in psychotics, treatment of insomnia, adjust therapy for endoscopic, procedures, relief of postoperative anxiety	Drowsiness, fatigue, ataxia, blurred vision, constipation, dry mouth, neutropenia, respiratory disorder, orthostatic hypotension	Smoking may decrease effectiveness, avoid use with alcohol, CNS depressant, may be habit-forming if used longer than 4 months. Do not discontinue abruptly after long term use.
risperidone	Antipsychotics / Antimanic agent	1mg	Oral	2times a day	Schizophrenia/ decreased symptoms of psychoses, bipolar mania, or autism.	Aggressive behavior, Extrapyramidal reaction Constipation Diarrhea Visual disturbances Decreased libido.	Check serum magnesium level prior administration, Assess for drug interaction, drug incompatibility

Ativan
Zoloft

Nursing Process Section

Nursing Diagnosis:

List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting.

Priority	Nursing Diagnosis	Related to	As Evidence By	Rationale (reason for priority)
1
2
3
4

Complete a table for the top two priorities listed in the table above. A minimum of 3 interventions are required for each nursing diagnosis, and one intervention must be an individual patient teaching and one must include a teaching for the patient’s family/caregivers (if applicable- i.e., patient is not homeless and/or has no family).

Table for Nursing Diagnosis Number 1

Assessment

· Signs and symptoms relative to the nursing diagnosis, as evidence by

· 2 objective

· 2 subjective

Patient Outcome

· SMART

· Specific

· Measurable

· Attainable

· Realistic

· Timely

Interventions/Implementations

· Includes interventions/ nursing actions directly relating to pt. outcomes

· Specific in action, frequency and contain rationale

· Minimum of 3 interventions appropriate to help pt./ family meet their outcomes

Evaluation

· Includes all data that is listed as criteria in outcomes

· Outcomes are determined to be met, partially met, or not met

· If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set

Table for Nursing Diagnosis Number 2

Assessment

· Signs and symptoms relative to the nursing diagnosis, as evidence by

· 2 objective

· 2 subjective

Patient Outcome

· SMART

· Specific

· Measurable

· Attainable

· Realistic

· Timely

Interventions/Implementations

· Includes interventions/ nursing actions directly relating to pt. outcomes

· Specific in action, frequency and contain rationale

· Minimum of 3 interventions appropriate to help pt./ family meet their outcomes

Evaluation

· Includes all data that is listed as criteria in outcomes

· Outcomes are determined to be met, partially met, or not met

· If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set

Best, best

Medications

Classification

Dose

Route

Purpose/Mechanism of Action

Significant Side Effects / Adverse Reactions

Nursing Implications

Table for Nursing Diagnosis Number 1

Assessment

· Signs and symptoms relative to the nursing diagnosis, as evidence by

· 2 objective

· 2 subjective

Patient Outcome

Interventions/Implementations

Evaluation

Table for Nursing Diagnosis Number 2

Assessment

· Signs and symptoms relative to the nursing diagnosis, as evidence by

· 2 objective

· 2 subjective

Patient Outcome

Interventions/Implementations

Evaluation