Posted: June 8th, 2023

PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

Student Name: Week: 6 Dates of Care:05/20/23

Patient Initials

F A Sex

M Age

95 Room

804 Admitting Date
05/19/23 Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

Fatigue and general weakness and experiencing pain in the lower back. The patient was brought by his son because he was too weak to get out of bed.

Attending physician/Treatment team:

Ayman M Jabr

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

Acute Pyelonephritis

ER Management: (if applicable)

Allergies:

No allergies
Code Status:
Full code Isolation: (type and reason)
Admission Height:

5’6 inches Admission Weight:

62kg (136 Ib 11 oz) Arm Band Location (colors & reasons)

Communication needs: (verbal, nonverbal, barriers, languages)
Patient speak Spanish only and

Past Medical History: (pertinent & how managed)

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 05/20/23 0735
T 99.2 F(37.3C)
P 85
R 18
B/P 132/78

Time 05/21/23 0755
T 98.6
P 75
R 18
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:
Helpive 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 11.5
RBC 3.55
HGB 11.5
HCT
MCV 90.3
MCH 29.3
MCHC 32.5
Platelets 260
RDW 15.9
MPV 8.3

PT
INR
APTT

Glucose 90
BUN 24
Creatinine 1.0
Sodium 3.5
Potassium 3.8
Cloride 1.08
Calcium 7.7
T Protein 6.1
Albumin 3.4
SGOT
SGPT
Alk Phos 98
Magnesium 1.6
Amylase
Lipase

CPK
LDH 34
Cholestrol 105

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.

Acute pyelonephritis is a bacterial infection that causes inflammation of the kidneys. It is usually caused by Escherichia coli and can be organ- and life-threatening, leading to kidney scarring. Diagnosing pyelonephritis can be done through urine testing, imaging tests, CT scans, and radioactive imaging. Urine testing is used to check for bacteria, concentration, blood, and pus in the urine, imaging tests to look for cysts, tumors, or other obstructions in the urinary tract, and radioactive imaging to track an injection of radioactive material. The most common etiologic agent of acute pyelonephritis is Escherichia coli.

The symptoms usually include fever, flank pain, nausea, vomiting, burning on urination, increased frequency, and urgency. Complications can include renal or perinephric abscess formation, sepsis, renal vein thrombosis, papillary necrosis, or acute renal failure. The treatment of acute pyelonephritis involves antibiotics, which are usually given intravenously in the hospital setting. In severe cases, surgery may be required to drain an abscess or remove a blockage in the urinary tract. The overall prognosis for acute pyelonephritis is generally good with prompt and appropriate treatment, but if left untreated or with complications, the prognosis can be poor. A coordinated, inter-professional team approach is essential to ensure prompt diagnosis, appropriate treatment, and close monitoring for complications.

Ramakrishnan, K., & Scheid, D. C. (2005). Diagnosis and management of acute pyelonephritis in adults. American family physician, 71(5), 933-942.

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 Acute Pain
Inflammation and infection of the urinary tact Report of pain/ burning discomfort when urinating The patient experienced severe pain during urination.
2 Hyperthermia
Inflammation process secondary to pyelonephritis
Increasing body temperature above the normal range The patient always has fever symptoms
3
Impaired Urinary elimination
Kidney infection and inflammation

Urinary retention
The patient experienced frequency and hesitancy urine
4

5

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

Lipitor

Atorvastatin

40mg

oral

daily
Inhibits HMG -COA retake enzyme which reduces cholesterol synthesis high dose lead to plaque regression Feeling sick (nausea), Headaches, diarrhea, runny nose, sore throat, constipation

Rocephin

Ceftriaxone

1g

oral

daily
Inhibits cell wall biosynthesis by Black tarry stool. Chest pain, shortness of breath. Sore throat, Swollen glands, and weakness

Plavix

Clopidogrel

75mg

oral

daily
Headaches, dizziness Nausea, Diarrhea, constipation, nosebleeds

Vasotec

Enalapril

10mg

oral

Daily Blurred vision itching or mild rash, diarrhea, Headaches

Tylenol

Heparin

Acetaminophen

650mg

650mg

oral

6 hours
Red, peeling or blistering skin, rash , hives, itching, and difficulty breathing

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)

Using Risk for Infection as the nursing diagnosis, the patient has acute pyelonephritis, which is an active bacterial infection of the kidneys

The patient has symptoms such as fever, nausea, and vomiting.
The patient also has a weakened immune system due to chronic kidney disease or frequent visits to hospitals.

The patient will maintain normal body temperature and vital signs within normal limits by the end of the shift.

The patient will remain free from the signs and symptoms of infection throughout hospitalization.

Short-term outcome:
The patient’s temperature and vital signs will be within normal limits by the end of the shift.

Long-term outcome:
The patient will remain free from signs and symptoms of infection throughout hospitalization, as evidenced by normal temperature, white blood cell count, and absence of fever, chills, nausea, vomiting, or malaise.
Short-term interventions:

Monitor vital signs every 4 hours.
Administer antibiotics as ordered.
Encourage adequate hydration.
Promote hygiene and infection control measures.

Long-term interventions:

Monitor temperature, white blood cell count, and signs and symptoms of infection.
Administer antibiotics.
Educate patient and family on infection prevention and control measures.
Collaborate with healthcare team to prevent healthcare-acquired infections.
The patient verbalized understanding of infection prevention and control measures before discharge.

The patient remained free from signs and symptoms of infection throughout hospitalization, as evidenced by normal temperature, white blood cell count, and absence of fever, chills, nausea, vomiting, or malaise.
The patient was discharged without any signs of infection.

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)

Acute Pain:
The patient has acute pyelonephritis, which can cause pain in the back or flank area.
The patient also has suprapubic symptoms of heaviness, pressure, or discomfort.

The patient may describe dysuria, and urgency to urinate.
Changes in urine odor and color also indicates bacteriuria
The patient will report a pain level of 3 or less on a scale of 0-10 within 30 minutes of receiving pain medication.

The patient will maintain a pain level of 3 or less on a scale of 0-10 throughout hospitalization.

Short-term outcome:

The patient’s pain level will be 3 or less on a scale of 0-10 within 30 minutes of receiving pain medication.
The patient will receive pain medication as ordered within 30 minutes of reporting pain.

Long-term outcome:

The patient will maintain a pain level of 3 or less on a scale of 0-10 throughout hospitalization, as evidenced by the patient’s self-report of pain level, facial expressions, and ability to perform activities of daily living.

The patient will be able to manage pain effectively at home, as evidenced by the patient’s ability to follow the prescribed pain management plan and report pain level accurately.
Short-term interventions:

Assess the patient’s pain level and location.
Administer pain medication as ordered.
Promote comfort measures such as heat therapy and positioning.
Encourage relaxation techniques such as deep breathing and guided imagery.

Long-term interventions:

Assess the patient’s pain level and location regularly.
Administer pain medication as ordered.
Educate patient and family on pain management strategies.
Collaborate with healthcare team to address underlying causes of pain.
The patient reported a pain level of 3 or less on a scale of 0-10 within 30 minutes of receiving pain medication.

The patient also maintained a pain level of 3 or less on a scale of 0-10 throughout hospitalization, as evidenced by the patient’s self-report of pain level, facial expressions, and ability to perform activities of daily living. The patient was discharged with adequate pain control.

I need help completing the Psycho/Social, Cultural/Spiritual needs, Growth & Development, Current Overall plan of care, Discharge plans and needs, Teaching needs, completing the medications sections, and putting in the normal lab values and its significance to the patient.

________________________-
Long-term outcome:

The patient will maintain a pain level of 3 or less on a scale of 0-10 throughout hospitalization, as evidenced by self-report and observation of comfort.

Short-term interventions:

Assess the patient’s pain level using a pain scale.
Administer pain medication as ordered and monitor for effectiveness.
Provide comfort measures such as positioning, warm compresses, and relaxation techniques.
Educate the patient on pain management strategies and encourage communication about pain.

Long-term interventions:

Assess the patient’s pain level regularly and reassess after interventions.
Administer pain medication as needed and monitor for side effects.
Provide ongoing comfort measures and address any additional pain relief needs.
Collaborate with the healthcare team to address underlying causes of pain and optimize pain management.

Assessment:

The patient reported a pain level of 3 or less on a scale of 0-10 within 30 minutes of receiving pain medication.
The patient maintained a pain level of 3 or less on a scale of 0-10 throughout hospitalization, as evidenced by self-report and observation of comfort.
The plan of care for pain management was continued, and the patient’s pain was regularly assessed and managed effectively.

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