PATIENT\/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET<\/p>\n
Student Name:<\/p>\n
Week:<\/p>\n
Dates of Care:<\/p>\n
Patient Initials<\/p>\n
E.R<\/p>\n
Sex<\/p>\n
M<\/p>\n
Age<\/p>\n
74<\/p>\n
Room<\/p>\n
1012<\/p>\n
Admitting Date<\/p>\n
1\/9\/2022<\/p>\n
Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?<\/p>\n
Chest PAIN, SOB<\/p>\n
Attending physician\/Treatment team:<\/p>\n
Juan C Villamizar. MD<\/p>\n
Consults:<\/p>\n
Respiratory Therapist<\/p>\n
Present Diagnosis: (Why patient is currently in the hospital)<\/p>\n
Pneumonia due to Covid-19<\/p>\n
ER Management: (if applicable)<\/p>\n
Allergies:<\/p>\n
Code Status:<\/p>\n
Full Code<\/p>\n
Isolation: (type and reason)<\/p>\n
Contact and Droplet<\/p>\n
Admission Height:<\/p>\n
5\u201910<\/p>\n
Admission Weight:<\/p>\n
144<\/p>\n
Arm Band Location (colors & reasons)<\/p>\n
Communication needs: (verbal, nonverbal, barriers, languages)<\/p>\n
Spanish\/English<\/p>\n
Past Medical History: (pertinent & how managed)<\/p>\n
Diabetes type 2, HTN, Pneumonia, acute kidney injury, CVA, Oropharyngeal dysphagia, smoker<\/p>\n
Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)<\/p>\n
Tests\/Treatments\/Interventions impacting clinical day\u2019s care (include current orders)<\/p>\n
Assessments and interventions: (Get custom essay samples and course-specific study resources via\u00a0course hero homework for you service – Include all pertinent data)<\/p>\n
Vital signs: (2 sets per day)<\/p>\n
Time<\/p>\n
0712<\/p>\n
T<\/p>\n
96.6<\/p>\n
P<\/p>\n
89<\/p>\n
R<\/p>\n
16<\/p>\n
B\/P<\/p>\n
108\/62<\/p>\n
Time<\/p>\n
T<\/p>\n
P<\/p>\n
R<\/p>\n
B\/P<\/p>\n
GI:<\/p>\n
Diet:<\/p>\n
Swallow precautions:<\/p>\n
Tube feedings:<\/p>\n
NG \/ G tube:<\/p>\n
Blood Glucose: (time & date)<\/p>\n
Last bowel movement: (time & date)<\/p>\n
Pertinent Labs\/Test:<\/p>\n
Assessments\/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)<\/p>\n
Respiratory:<\/p>\n
02 modalities:<\/p>\n
02 Saturation:<\/p>\n
Suction:<\/p>\n
Resp Rx\u2019s:<\/p>\n
Trach:<\/p>\n
Chest Tubes:<\/p>\n
Pertinent Labs\/Test:<\/p>\n
Assessments\/Interventions: (Lung sounds, cough, sputum, SOB)<\/p>\n
Neurosensory:<\/p>\n
Neuro checks:<\/p>\n
Alert & Orientated:<\/p>\n
Follows commands:<\/p>\n
Speech Comprehensible:<\/p>\n
Pertinent Labs\/Test:<\/p>\n
Assessments\/Interventions:<\/p>\n
(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)<\/p>\n
Cardiovascular:<\/p>\n
Telemetry:<\/p>\n
Pacemaker\/IAD:<\/p>\n
DVT Prevention:<\/p>\n
Daily Weights:<\/p>\n
Pertinent Labs\/Test:<\/p>\n
Assessments\/Interventions:<\/p>\n
(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)<\/p>\n
Musculoskeletal:<\/p>\n
Activity:<\/p>\n
Traction:<\/p>\n
Casts\/Slings:<\/p>\n
Pertinent Labs\/Test:<\/p>\n
Assessments\/Interventions:<\/p>\n
(strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps<\/p>\n
Renal:<\/p>\n
Catheter (indwelling\/external):<\/p>\n
CBI:<\/p>\n
Dialysis:<\/p>\n
A\/V access:<\/p>\n
Pertinent Labs\/Test:<\/p>\n
Assessments\/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O)<\/p>\n
Skin:<\/p>\n
Braden Score:<\/p>\n
Pertinent Labs\/Test:<\/p>\n
Assessments\/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)<\/p>\n
Pain:<\/p>\n
Pain score:<\/p>\n
Assessments\/Interventions:<\/p>\n
(scale used, location, duration, intensity, character, exacerbation, relief, interventions)<\/p>\n
Vascular Access: (IV site)<\/p>\n
Assessments\/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)<\/p>\n
Gyn:<\/p>\n
Gravida\/Para:<\/p>\n
LMP:<\/p>\n
Last Pap:<\/p>\n
Breast exam:<\/p>\n
Pertinent Labs\/Test<\/p>\n
Assessment\/Interventions: (bleeding, discharge)<\/p>\n
Post-operative \/procedural:<\/p>\n
Assessments\/Interventions:<\/p>\n
(immediate post procedure care)<\/p>\n
Safety:<\/p>\n
Call light:<\/p>\n
Bed Rails:<\/p>\n
Bed alarms:<\/p>\n
Fall risk:<\/p>\n
Assistive Devices:<\/p>\n
Sitter use:<\/p>\n
Restraints (type, duration & reason):<\/p>\n
Assessment\/Interventions (modifications to room, environment, Patient)<\/p>\n
Advance Directives\/Ethical considerations:<\/p>\n
DPOA:<\/p>\n
Hospice:<\/p>\n
Pertinent Data (Labs, X-rays, Etc.)<\/p>\n
Results<\/p>\n
Normal Lab Values<\/p>\n
Significance to your patient<\/p>\n
WBC<\/p>\n
RBC<\/p>\n
HGB<\/p>\n
HCT<\/p>\n
MCV<\/p>\n
MCH<\/p>\n
MCHC<\/p>\n
Platelets<\/p>\n
RDW<\/p>\n
MPV<\/p>\n
PT<\/p>\n
INR<\/p>\n
APTT<\/p>\n
Glucose<\/p>\n
BUN<\/p>\n
Creatinine<\/p>\n
Sodium<\/p>\n
Potassium<\/p>\n
Cloride<\/p>\n
Calcium<\/p>\n
T Protein<\/p>\n
Albumin<\/p>\n
SGOT<\/p>\n
SGPT<\/p>\n
Alk Phos<\/p>\n
Magnesium<\/p>\n
Amylase<\/p>\n
Lipase<\/p>\n
CPK<\/p>\n
LDH<\/p>\n
Cholestrol<\/p>\n
CK<\/p>\n
CK-MB<\/p>\n
Troponin I<\/p>\n
Myoglobin<\/p>\n
LDI<\/p>\n
Urinalysis<\/p>\n
Color<\/p>\n
Character<\/p>\n
Spec. Grav.<\/p>\n
pH<\/p>\n
Protein<\/p>\n
Glucose<\/p>\n
Acetone<\/p>\n
Bilirubin<\/p>\n
Blood<\/p>\n
Nitr<\/p>\n
Urobili<\/p>\n
RBC<\/p>\n
WBC<\/p>\n
Epithelium<\/p>\n
Urine Culture<\/p>\n
Chest X-ray<\/p>\n
MRI<\/p>\n
CT Scan<\/p>\n
Others test:<\/p>\n
Psycho\/Social: Assessment\/Interventions:(mental illness, social history, living arrangements, primary care giver, substance abuse, maternal\/infant bonding, family dynamics)<\/p>\n
Cultural\/Spiritual needs: Assessment\/Interventions: (religious preference, adaptations & modifications, end of life decisions)<\/p>\n
Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient:<\/p>\n
Current overall plan of care: (A short statement that summarizes the anticipated plan of care)<\/p>\n
Discharge plans and needs:<\/p>\n
Teaching needs:(Disease process, medications, safety, style, barriers)<\/p>\n
Pathophysiological Ace my homework – Write my paper – Online assignment help tutors – Discussion: Ace my homework – Write my paper – Online assignment help tutors – 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\u2019s 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\u2019s overall prognosis. Get custom essay samples and course-specific study resources via\u00a0course hero homework for you service – Include appropriate references and use Ace homework tutors – APA format.<\/p>\n
ADH II: attach a research article pertaining to diagnosis of patient. Ace my homework – Write a summary about the article.<\/p>\n
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.<\/p>\n
Priority<\/p>\n
Nursing Diagnosis<\/p>\n
Related to<\/p>\n
As Evidence By<\/p>\n
Rationale (reason for priority)<\/p>\n
1<\/p>\n
2<\/p>\n
3<\/p>\n
4<\/p>\n
5<\/p>\n
Medications
\nClassification
\nDose
\nRoute
\nFreq<\/p>\n
Purpose\/Mechanism of Action
\nSignificant Side Effects \/ Adverse Reactions
\nNursing Implications<\/p>\n
Nursing Diagnosis: Identify the top two nursing Diagnoses and expand<\/p>\n
Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Get custom essay samples and course-specific study resources via\u00a0course hero homework for you service – Include s objective & Subjective historical data that support actual or risk for nursing diagnosis)
\nPatient Goal(s)
\nStatement of purpose for the patient to achieve<\/p>\n
Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)
\n(Must have at least two short term outcomes and two long term outcomes)<\/p>\n
Interventions\/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient\u2019s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.
\nEvaluation. (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)
\nNursing Diagnosis: Identify the top two nursing Diagnoses and expand<\/p>\n
Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Get custom essay samples and course-specific study resources via\u00a0course hero homework for you service – Include s objective & Subjective historical data that support actual or risk for nursing diagnosis)
\nPatient Goal(s)
\nStatement of purpose for the patient to achieve<\/p>\n
Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)
\n(Must have at least two short term outcomes and two long term outcomes)<\/p>\n
Interventions\/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient\u2019s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.
\nEvaluation. (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)
\nPAGE<\/p>\n
1<\/p>\n
—<\/p>\n
PATIENT\/CLIENT DATA – WORKSHEET FOR CLINICAL DECISION-MAKING<\/p>\n
Name of the student:<\/p>\n
Week:<\/p>\n
Dates of Care:<\/p>\n
Patient Initials<\/p>\n
E.R<\/p>\n
Sex<\/p>\n
M<\/p>\n
Age<\/p>\n
74<\/p>\n
Room<\/p>\n
1012<\/p>\n
Admitting Date<\/p>\n
1\/9\/2022<\/p>\n
Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?<\/p>\n
Chest PAIN, SOB<\/p>\n
Attending physician\/Treatment team:<\/p>\n
Juan C Villamizar. MD<\/p>\n
Consults:<\/p>\n
Respiratory Therapist<\/p>\n
Present Diagnosis: (Why patient is currently in the hospital)<\/p>\n
Pneumonia due to Covid-19<\/p>\n
ER Management: (if applicable)<\/p>\n
Allergies:<\/p>\n
Code Status:<\/p>\n
Full Code<\/p>\n
Isolation: (type and reason)<\/p>\n
Contact and Droplet<\/p>\n
Admission Height:<\/p>\n
5\u201910<\/p>\n
Admission Weight:<\/p>\n
144<\/p>\n
Arm Band Location (colors & reasons)<\/p>\n
Communication needs: (verbal, nonverbal, barriers, languages)<\/p>\n
Spanish\/English<\/p>\n
Past Medical History: (pertinent & how managed)<\/p>\n
Diabetes type 2, HTN, Pneumonia, acute kidney injury, CVA, Oropharyngeal dysphagia, smoker<\/p>\n
Significant Events during this hospitalization but not during this clinical time<\/p>\n","protected":false},"excerpt":{"rendered":"
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\u2026<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2468,274,2469,53,2471,354,2470,2467],"tags":[2472,1427,1656,1648,2473,2386,1966],"class_list":["post-5928","post","type-post","status-publish","format-standard","hentry","category-bsn-papers","category-dnp-assignment","category-health-care-essays","category-masters-essays","category-nursing-assessment","category-nursing-assignment","category-nursing-homework","category-nursing-papers-homework-help","tag-healthcare-dissertations","tag-healthcare-essays","tag-medical-papers","tag-medical-research-papers","tag-msn-essays","tag-nursing-case-study","tag-nursing-essays"],"_links":{"self":[{"href":"https:\/\/www.studyproessays.com\/nursing\/wp-json\/wp\/v2\/posts\/5928","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.studyproessays.com\/nursing\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.studyproessays.com\/nursing\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.studyproessays.com\/nursing\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.studyproessays.com\/nursing\/wp-json\/wp\/v2\/comments?post=5928"}],"version-history":[{"count":0,"href":"https:\/\/www.studyproessays.com\/nursing\/wp-json\/wp\/v2\/posts\/5928\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.studyproessays.com\/nursing\/wp-json\/wp\/v2\/media?parent=5928"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.studyproessays.com\/nursing\/wp-json\/wp\/v2\/categories?post=5928"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.studyproessays.com\/nursing\/wp-json\/wp\/v2\/tags?post=5928"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}