Posted: June 1st, 2023

Week6 MHCarePlan NUR4020

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PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

Student Name: Week: 2 Dates of Care:5/20/2023

Patient Initials

CV Sex

M Age

47 Room

837 Admitting Date

5/19/2023 Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

Intractable headache

Attending physician/Treatment team:

Ayman M. Jabr, MD

Consults:

No consult
Present Diagnosis: (Why patient is currently in the hospital)

Headache and dizziness

ER Management: (if applicable)

Nile Township high school

Allergies:

Shrimp, Ibuprofen, Aspirin
Code Status:

Full code Isolation: (type and reason)

none
Admission Height:

165.1 centimeters (5,5) Admission Weight:

107.9 kilograms (237 lbs) Arm Band Location (colors & reasons)
on the right arm and it’s white

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

the patient has no communication barriers

Past Medical History: (pertinent & how managed)

diabetes mellitus
gerd
hypertension
obstructive sleep apnea
sciatica
spinal stenosis
degenerative joint disease

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 8: 00
T 98.6
P 96
R 18
B/P 138/80

Time 13: 00
T 97.9
P 98
R 20
B/P 111/73
GI:

Diet: Regular
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: 96
Suction:
Resp Rx’s:
Trach: none
Chest Tubes: none
Pertinent Labs/Test:
Assessments/Interventions: (Lung sounds, cough, sputum, SOB)

Neurosensory:

Neuro checks:
Alert & Orientated: x4
Follows commands: yes
Speech Comprehensible: yes
Pertinent Labs/Test:
Assessments/Interventions:
(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)
patient had dizziness and headache
Cardiovascular:

Telemetry:
Pacemaker/IAD:
DVT Prevention: heparin (5000 units)
Daily Weights:
Pertinent Labs/Test:
Assessments/Interventions:
(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)
Musculoskeletal:

Activity: independent
Traction: none
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: 10 in the head
Assessments/Interventions: acetaminophen was given
(scale used, location, duration, intensity, character, exacerbation, relief, interventions)
morphine

Vascular Access: (IV site)

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

Gyn:

Gravida/Para: none
LMP: none
Last Pap: none
Breast exam: none
Pertinent Labs/Test
Assessment/Interventions: (bleeding, discharge) none

Post-operative /procedural:

Assessments/Interventions: none
(immediate post procedure care)

Safety:

Call light:
Bed Rails:
Bed alarms: no need
Fall risk: not at 4 risk
Helpive Devices: none
Sitter use: none
Restraints (type, duration & reason):
Assessment/Interventions (modifications to room, environment, Patient)

Advance Directives/Ethical considerations:

DPOA: has no advanced directives
Hospice:

Pertinent Data (Labs, X-rays, Etc.) Results Normal Lab Values Significance to your patient
WBC 7.2
RBC 5.37
HGB 17.3
HCT 48.9
MCV 91.0
MCH 32.3
MCHC 35.5
Platelets 207
RDW 14.5
MPV 8.3
CBC
PT
INR
APTT

Glucose 225
BUN 14
Creatinine 0.86
Sodium 134
Potassium 5.3
Cloride 97
Calcium 9.0
T Protein 6.4
Albumin 3.8
SGOT
SGPT
Alk Phos 69
Magnesium
Amylase
Lipase

CPK
LDH
Cholestrol

CK
CK-MB
Troponin I
Myoglobin
LDI

Urinalysis
Color
Character
Spec. Grav.
pH
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

2

3

4

5

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

Ascorbic acid (Vitamin C)

100 mg tablet Oral Daily

Atorvastatin (Lipitor)

10 mg tablet Oral Daily

Dexamethasone (Decdron)

8mg IM Injection Intravenous

Acetaminophen

650 mg Orally PRN

Diphenhydramin (Benadryl)

25 mg injection Injection Intravenous

Enalapril (Vasotech)

10 mg Oral Daily

Furosemide (Lasix)

40 mg Oral Daily

Glucagon

1 mg IM PRN

Heparin

5000 units IM Continuous
Insulin Aspart (Novolog) 18 units IM, Subcontanous 3 times daily with meals

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

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