PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET
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Student Name: |
Week: 4 |
Dates of Care: |
Patient Initials
Sex
M
Age
7
7
Room
7
1
6
Admitting Date
Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?
Shortness of breath, fever, and chills
Attending physician/Treatment team:
Consults:
Present Diagnosis: (Why patient is currently in the hospital)
ER Management: (if applicable)
Allergies:
No Known Allergies
Code Status:
DNR
Isolation: (type and reason)
Admission Height:
Admission Weight:
Arm Band Location (colors & reasons)
Left
Communication needs: (verbal, nonverbal, barriers, languages)
Verbal, Spanish speaking, needs an interpreter.
Past Medical History: (pertinent & how managed)
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) |
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Assessments and interventions: (Include all pertinent data) |
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Vital signs: ( 2 sets per day) Time T P R B/P 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) |
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Respiratory: 02 modalities: 02 Saturation: 98% Suction:
N/A Resp Rx’s: N/A Trach: N/A Chest Tubes: N/A Pertinent Labs/Test: Chest X-ray noted worsening hazy density in the left midlung may reflect edema, atelectasis, or nonspecific pneumonitis. Assessments/Interventions: (Lung sounds, cough, sputum, SOB) Lung sound was clear, no cough, no sputum, no SOB. |
Neurosensory: Neuro checks: No Alert & Orientated: x4 Follows commands: yes Speech Comprehensible: yes Pertinent Labs/Test: No pertinent labs/test Assessments/Interventions: (LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness) Followed Cardinal Field of Gaze. No tremors, tingling, numbness, paralysis, headaches, dizziness. Glasgow coma scale: 1 5 , no head trauma. |
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Cardiovascular: Telemetry: Yes Pacemaker/IAD: No DVT Prevention: N/A Daily Weights: N/A Pertinent Labs/Test: No pertinent labs/test Assessments/Interventions: (Peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations) Pulse is regular in S1/S2, rate 78, no abnormal sounds heard, pacemaker no telemetry. No edema, chest pain, discomfort, palpitations. |
Musculoskeletal: Activity: As tolerated Traction: N/A Casts/Slings: N/A Pertinent Labs/Test: No pertinent labs/test Assessments/Interventions: (Strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps Followed ROM. No pain, fractures, amputation. Gait is steady. Slight weakness, age related. |
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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) Patient has a urinal and a commode by his bedside. Urine is yellow in color. No burning with urination, no hematuria, no incontinence, no monitoring of I & O. Patient drinks adequate amount of water. |
Skin: Braden Score: 1 3 Pertinent Labs/Test: No pertinent labs/test Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toenails, wounds, drains, bed type) Has slight bruising on left arm, red no blanching. Skin turgor 3 secs. No surgical incisions. No edema. No wounds, no drains. General medicine bed. |
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Pain: Pain score: 0 Assessments/Interventions: N/A (scale used, location, duration, intensity, character, exacerbation, relief, interventions) Numerical pain scale, Patient was not in any pain. |
Vascular Access: (IV site) Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance) Peripheral, left antecubital, 22 gauge, inserted Pt was on an antibiotic Arythromycin in NaCl 0.9% IVPB. Site appeared: no redness or bruising. |
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Gyn: Gravida/Para: LMP: Last Pap: Breast exam: Pertinent Labs/Test Assessment/Interventions: (bleeding, discharge) N/A Male Patient |
Post-operative /procedural: Assessments/Interventions: (immediate post procedure care) N/A No Post op |
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Safety: Call light: Yes Bed Rails: Yes Bed alarms: No Fall risk: No Assistive Devices: No Sitter use: No Restraints (type, duration & reason): Assessment/Interventions (modifications to room, environment, Patient) N/A No modifications were made to the patient’s room. |
Advance Directives/Ethical considerations: DPOA: Yes, his wife. Hospice: N/A |
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Pertinent Data (Labs, X-rays, Etc.) Results Normal Lab Values Significance to your patient WBC 12.3 4.5-11.0 RBC 4.26 4.5-5.5 HGB 13.5 g/dL 13-18 g/dL HCT 40.6% 39-54% MCV 95.2 fL 80-100 fL MCH 31.7 pg 27.5-33.2 pg MCHC 33.3 g/dL 33.4- 35 .5 g/dL Platelets 225 150000-450000 RDW 14.0% 11.8-14.5 % MPV 10.0 fL 7.5-12.0 fL PT N/A INR N/A APTT N/A Glucose 89 < 140 mg/dL BUN 35 7-20 mg/dL Creatinine 1.05 0.6-1.2 mg/dL Sodium 140 135-145 mEq/L Potassium 3.9 3.5-5.0 mEq/L Cloride 103 95-105 mEq/L Calcium 9.7 9-11 mg/dL T Protein 7.2 6.2-8.2 g/dL Albumin 3.9 3.4-5.4 g/dL SGOT N/A SGPT N/A Alk Phos N/A Magnesium N/A Amylase N/A Lipase N/A CPK N/A LDH N/A Cholestrol N/A CK N/A CK-MB N/A Troponin I N/A Myoglobin N/A LDI N/A Urinalysis Color Yellow Pale yellow – deep amber Character Cloudy Clear Spec. Grav. 1.023 1.010-1.030 pH 7 4.6-8.0 Protein N/A N/A Acetone N/A Bilirubin N/A Blood N/A Nitr N/A Urobili N/A 21-50 0-5 per hpf WBC 21-50 Epithelium Many 0-2 per hpf Urine Culture Blood pending Urine pending Chest X-ray MRI N/A CT Scan N/A Others test: Covid 19 test Negative Negative/ Positive |
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Psycho/Social: Assessment/Interventions:(mental illness, social history, living arrangements, primary care giver, substance abuse, maternal/infant bonding, family dynamics) |
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Cultural/Spiritual needs: Assessment/Interventions: (religious preference, adaptations & modifications, end of life decisions) |
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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.
Benign prostatic hyperplasia (BPH) is when your prostate gland is enlarged, it is a common condition in older men, specifically African American men. BPH can cause urinary symptoms such as weak flow of urine, urine retention, trouble starting to urinate. BPH can get worse with age. Researchers do not know the direct cause to what the cause of BPH is, some research has shown that high levels of dihydrotestosterone push the prostate cells to continue to grow. Non modifiable risk factors: age, geography, and genetics. Modifiable risk factors: physical activity, obesity, diabetes, and diet. BPH is diagnosed by digital rectal exam, urine test, blood test, and prostate-specific antigen (PSA) blood test. Treatment of BPH depends on the overall health of the patient, age of the patient, and size of the prostate. If symptoms are tolerable the doctor might start off with medications first. Medications that can help treat symptoms of BPH are alpha blockers like tamsulosin, which my patient is prescribed, it relaxes the bladder neck muscles in the prostate. 5-alpha reductase inhibitors, finasteride which shrinks the prostate by preventing hormonal changes that cause the prostate to grow. Invasive procedures for BPH are transurethral resection of the prostate (TURP) which is “A lighted scope is inserted into your urethra, and the surgeon removes all but the outer part of the prostate” (Mayo Clinic 2020). Laser therapy “A high-energy laser destroys or removes overgrown prostate tissue” (Mayo Clinic 2020). Laser therapies include ablative & enucleative procedures. My patient currently takes his medication when he is supposed to with help from his caregiver. His BPH is under control. He has never had to get invasive surgery.
https://www.mayoclinic.org/diseases-conditions/benign-prostatic-hyperplasia/diagnosis-treatment/drc-20370093
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 |
Risk for impaired skin integrity |
Pressure over bony prominence |
Immobility |
Other than using the bathroom, the patient stays in bed. |
| 2 | ||||
| 3 | ||||
| 4 | ||||
| 5 |
| Medications | Classification | Dose | Route |
Freq |
Purpose/Mechanism of Action | Significant Side Effects / Adverse Reactions | Nursing Implications | ||||
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Tamsulosin |
Alpha 1 Blockers |
0.4 mg |
Oral |
bid |
Purpose Treats men with symptoms of BPH. It can also treat kidney stones MOA Antagonist of alpha 1A adrenoceptors in the prostate. |
Lightheadedness, abnormal ejaculation, drowsiness, runny nose, dizziness, decreased amount of semen, weakness, chest pain. |
1. Caution should be exercised when administering to patients with sulfa allergy 2. Patient should be screened for prostate cancer before administration of this drug. |
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Ascorbic acid (Vitamin C) |
Vitamin C |
1,000mg |
Daily |
Purpose Helps heals wounds, enhances absorption of iron, and support the immune system. MOA Ascorbic acid is reversibly oxidized to dehydroascorbic acid (vitamin c) in the body |
Nausea, vomiting, heartburn, stomach cramps, headache, injection site soreness, dizziness. |
1. Patients on anticoagulant therapy should not take excessive doses of vitamin C over an extended period of time. 2. Caution should be exercised when administering vitamin C to nursing women. |
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Enalapril |
ACE inhibitor |
5 mg |
1 Tab q12h |
Purpose Inhibits ACE Mechanism of Action Decreases the levels of angiotensin II leading to lower BP. |
Headache, blurred vision, mild skin rash, lightheadedness |
Avoid getting up to fast from a sitting or lying position. Monitor blood pressure. Monitor renal functions. Avoid potassium sparing diuretics. |
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Ferrous sulfate |
Vitamin Iron |
324 mg |
1 Tab bid |
Purpose Treats and prevents iron deficiency. Mechanism of Action Iron combines with porphyrin and globin chains to form hemoglobin. |
Constipation, diarrhea, stomach cramps, dark stool, N/V. |
Take on empty stomach. Avoid taking antacids or antibiotics within 2hrs before or after taking drug Stool may be dark |
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Metformin |
Biguanides |
500 mg |
Purpose Helps control the amount of glucose in your blood. Mechanism of Action Decreases hepatic glucose production, decreases intestinal absorption of glucose and improves insulin sensitivity by increasing peripheral glucose uptake and utilization. |
Heartburn, N/V, stomach pain, weight loss, constipation, bloating. |
Take drug with meals Do not break, chew, crush. Blood sugar should be taken before administration. Renal functions should be monitored for 3-6 months. |
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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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