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PATIENT/CLIENT DATA - CLINICAL DECISION-MAKING WORKSHEET

Student Name: Olufunke Onifade

Week:

Dates of Care: 3/28/21

Demographics and Brief History

Patient Initials

C.A

Sex

Age

Room

1521

Admitting Date

3/14/2021

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

Bipolar disorder, current episode of manic. Severe with psychiatric features

Attending physician/Treatment team:

Mitchell L. Glaser MD

Diana Tomala, MA-LPC

Erin R. Golger RN

Precautions:

Droplet precautions

Contact precautions

Primary Diagnosis:

Bipolar Disorder

Co-morbidities:

None

Allergies:

Penicillin, peanut, shellfish

Code Status:

Full code

Isolation: (type and reason)

None

Admission Height: 5.3

Admission Weight:72kg

(158lb 12.8 oz)

Arm Band Location (colors & reasons)

Right

Past Medical History: (pertinent & how managed)

No past medical history

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	1400	1700
T	97 degree Celsius	99 degree Celsius
P	110	112
R	20	19
B/P	115/67	120/67

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): Morning

Last bowel movement (time & date): Morning

Pertinent Labs/Test: None

Assessments:

· Stool

· Bowel sounds

· Tenderness, distention

· Appetite, nausea, vomiting

Interventions: Bowel sound was clear. There was no form of distention, loss of appetite, nausea and vomiting

Respiratory:

Assessments:

· Lung sounds

· Cough, sputum

· SOB

Interventions: There was no form of sputum, the lung sounds were clear and bilateral at the anterior and posterior parts of the clients body.

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: 24

Pertinent Labs/Test: None at the time of visit

Assessments

· Bruising, wounds, drains

· Turgor

· Surgical incisions

· Finger & toe nails

Interventions: The patient was free from edema and bruising. The nails were well kept and neat.

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	10.7	4011	Not applicable
RBC	4.59	4.7 to 6.1	Not applicable
HGB	13.8	13.5 to 17.5	Not applicable
HCT	40.9	36.1 to 44.3	Not applicable
MCV	89.2	80 to 60	Not applicable
MCH	30.0	27.5 to 33.5	Not applicable
MCHC	33.7	33 to 35.5	Not applicable
Platelets	422	150,000 to 450,000	Not applicable
RDW	13.8	12.2 to 16.1	Not applicable
MPV	8.1	7.5 to 12.0	Not applicable
Glucose	113	100 to 125	Not applicable
BUN	15	2.5 to 7.1	Not applicable
Creatinine	0.62	0.84 to 1.21	Not applicable
Sodium	139	135 to 145	Not applicable
Potassium	3.5	3.6 to 5.2	Not applicable
Cloride	102	96 to 106	Not applicable
Calcium	10.3	8.6 to 10.3	Not applicable
Salicylate	25	15 to 30	Not applicable

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

· Has a high school diploma

· Occupation

· Not on file

· Race/Ethnic Background or Identification

· Africa American

· Religion/Spiritual Beliefs

· Christian

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

· verbal

· Special Talents/Interests/Skills

· swimming

· Environment (home and community)

· home

· Family Structure/History:

In a nuclear family

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)

This patient is in the Generativity versus stagnation of the Erikson stage of development and she

Successfully completed her previous stages.

Support System:

Stressors/Stress Management Practices:

Reading and swimming

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:

Suicide

Homicide

Addiction

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

Medications	Classification	Dose	Route	Freq	Purpose/Mechanism of Action	Significant Side Effects / Adverse Reactions	Nursing Implications

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

Love,love

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