Use the information in the attached file to develop a care plan. Please ask if you need additional information.
PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET
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Student Name: |
Week: |
Dates of Care: |
Patient Initials
O.S
Sex
F
Age
6
1
Y/O
Room
8
2
0
Admitting Date
01/21/22
Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?
Fever, vomiting, SOB, fatigue
Attending physician/Treatment team:
S E P MD
Consults:
Present Diagnosis: (Why patient is currently in the hospital)
Acute Kidney Injury on
CKD III
ER Management: (if applicable)
None recorded
Allergies:
No known allergies
Code Status:
Full code
Isolation: (type and reason)
None
Admission Height:
160 cm (
5
’
3
inch)
Admission Weight:
76 kg (167 lb)
(Arm Band Location (colors & reasons)
Yellow band: Fall risk
White band: Patient ID
Communication needs: (verbal, nonverbal, barriers, languages)
Speaks English well, no language barrier
Past Medical History: (pertinent & how managed)
High cholesterol,
Hypertension
Lupus
History of cholecystectomy
Reynaud’s disease
Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)
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Tests/Treatments/Interventions impacting clinical day’s care (include current orders) Kidney biopsy |
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Assessments and interventions: (Include all pertinent data) |
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Vital signs: (2 sets per day) Time 1700 2012 T 98.7 F (oral) 98.3 (oral) P 88 78 R 18 18 B/P 135/86 121/76 Time 083 4 1215 T 99.9F (oral) 100.1 P 76 78 R 20 20 B/P 127/65 134/70 |
GI: Diet: Renal diet Swallow precautions: Tube feedings: NG / G tube: Blood Glucose: (time & date) Last bowel movement: (time & date) 1/23/22 Pertinent Labs/Test: Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting) |
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Respiratory: 02 modalities: Intermittent 02 Saturation: 97% Suction: Resp Rx’s: Trach: Chest Tubes: 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: None Assessments/Interventions: (LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness) |
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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 Active ROM strength |
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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) Skin is dry, no discoloration noted upon assessment |
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Pain: Pain score: Reports previous lower back pain Assessments/Interventions: (scale used, location, duration, intensity, character, exacerbation, relief, interventions) Patient stated Patient received acetaminophen 650mg for mild pain. Goal of zero pain outcome was reached |
Vascular Access: (IV site) right antecubital peripheral IV Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance) Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance) IV site has no redness, edema, tenderness, or drainage. Intervention: continue to monitor IV site for infiltration, any skin breakdown. Continue to administer IV fluids as ordered. Change IV site per protocol. |
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Gyn: Gravida/Para: Nullipara LMP: Last Pap: Breast exam: Pertinent Labs/Test Assessment/Interventions: (bleeding, discharge) |
Post-operative /procedural: Assessments/Interventions: (immediate post procedure care) |
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Safety: Call light: Bed Rails: Bed alarms: Fall risk: Assistive Devices: Sitter use: Restraints (type, duration & reason): None Assessment/Interventions (modifications to room, environment, Patient) |
Advance Directives/Ethical considerations: DPOA: Hospice: |
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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: |
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Psycho/Social: Assessment/Interventions:(mental illness, social history, living arrangements, primary care giver, substance abuse, maternal/infant bonding, family dynamics) Married , no child , use alcohol socially, no drug use , feeling stressed |
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Cultural/Spiritual needs: Assessment/Interventions: (religious preference, adaptations & modifications, end of life decisions) Patient is a Christian catholic |
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Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient: |
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Current overall plan of care: (A short statement that summarizes the anticipated plan of care) |
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Discharge plans and needs: |
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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.
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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 |
|
Ondansetron |
4mg |
SubQ |
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Pantoprazole |
40mg |
PO |
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Acetaminophen |
650mg |
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Amlodipine |
10mg |
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Ampicillin Sulbactam Sodium chloride 0.9% |
3g |
IV |
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Enalapril Vasotec |
20mg |
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Heparin |
500 units |
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Hydroxychloroquine 200mg |
200mg |
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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. | Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set) | |||
Nursing Diagnosis: Identify the top two nursing Diagnoses and expand
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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) |
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