Posted: February 19th, 2022

PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

Student Name:

Week:

Dates of Care:

Patient Initials

E.R

Sex

M

Age

74

Room

1012

Admitting Date

1/9/2022

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

Chest PAIN, SOB

Attending physician/Treatment team:

Juan C Villamizar. MD

Consults:

Respiratory Therapist

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

Pneumonia due to Covid-19

ER Management: (if applicable)

Allergies:

Code Status:

Full Code

Isolation: (type and reason)

Contact and Droplet

Admission Height:

5’10

Admission Weight:

144

Arm Band Location (colors & reasons)

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

Spanish/English

Past Medical History: (pertinent & how managed)

Diabetes type 2, HTN, Pneumonia, acute kidney injury, CVA, Oropharyngeal dysphagia, smoker

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

0712

T

96.6

P

89

R

16

B/P

108/62

Time

T

P

R

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

RBC

HGB

HCT

MCV

MCH

MCHC

Platelets

RDW

MPV

PT

INR

APTT

Glucose

BUN

Creatinine

Sodium

Potassium

Cloride

Calcium

T Protein

Albumin

SGOT

SGPT

Alk Phos

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.

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

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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PATIENT/CLIENT DATA – WORKSHEET FOR CLINICAL DECISION-MAKING

Name of the student:

Week:

Dates of Care:

Patient Initials

E.R

Sex

M

Age

74

Room

1012

Admitting Date

1/9/2022

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

Chest PAIN, SOB

Attending physician/Treatment team:

Juan C Villamizar. MD

Consults:

Respiratory Therapist

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

Pneumonia due to Covid-19

ER Management: (if applicable)

Allergies:

Code Status:

Full Code

Isolation: (type and reason)

Contact and Droplet

Admission Height:

5’10

Admission Weight:

144

Arm Band Location (colors & reasons)

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

Spanish/English

Past Medical History: (pertinent & how managed)

Diabetes type 2, HTN, Pneumonia, acute kidney injury, CVA, Oropharyngeal dysphagia, smoker

Significant Events during this hospitalization but not during this clinical time

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