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Clinical Review

Indiana Dabney University WILLIE B. THURMOND SCHOOL OF NURSING PROGRAM

Clinical Review Part 2


Print Student Name: ____ Print Instructors Name: ____ Date: ___ Clinical Area/Session: __

DIRECTIONS: Complete this session after you have completed Part 1 Pt Initials: ___ Rm: __ Age: __ Admission Date: __ Occupation: ___

Marital Status: __Married

Race___ Black/African American Gender: __ Male Allergies: __Denied


Code Status: ________________________ Advance Directive (Type): ___Living Will, No organ or tissue donor Admitting Diagnosis: ____CVA with contractures, parkinsons disease, Hypertension, congestive heart failure, diabetes mellitus insulin dependent, glaucoma, multi-drug resistant organism, high cholesterol, renal insufficiency, DVT to right lower leg, G-tube, cataracts, trach-closed 4/21/2011 Chief Complaint on Admission: __renal failure Chief Complaint Presently: ___renal insufficiency Surgical Procedure(s) with dates: ___ Past Chronic conditions: ___diabetes mellitus, hypertension, parkinsons disease

Clinical Review Involvement of family and/or significant other: __close to his wife Religion: __ Christian Community and home: ___________________________________________________________ Ethic-Cultural influences: _______________________________________________________ Financial status (Worries about taking care of family, parents, job or unemployed, adequate income, worries, etc.): ________________________________________________________

Risk Factors: X Heart Alcohol

Resp Drugs

DM Obesity

Smoking (packs per day: __________ Life Style:

Family Hx of: __HTN, Alzheimers-mom & sibling, CA-dad, parkinsons-Sister, MI-brother Level of Consciousness: ___x2 Restraints: _______ Assistive Devices: ___complete immobile

Activity Order: _______________ Current Activity: _______________ ROM: _____________ Oxygen: No: __X If Yes amount: __________ Delivery Method: __Room air

IV Orders: Current Order Solution: ______ Amount: ____________ Purpose: ________________________________ IV site Intact with good blood return: Yes: ___ No: ___ What did you do if no blood return?: _________________ Diet type: ___ Appetite: ________________________Feeder: ______________ Description: __very loose

BM Status: Date of last BM: ___7/7/11

Catheter: _urinary catheter

Drains: __2 wound vacs

Tubes: __G-tube

Clinical Review NG or G Tube: __X Date 7/7/11 Intake Suctioning: ____ or Feeding Rate: __70mL Output 650mL On Adm Temp. Pulse Resp. B/P Pedal Pulse Rt Lt Flush amt & time: 150mL of water q6hrs Day Before 98.7 78 27 133/73 1+ 1+ 2+ X 2+ X Current 98.4 70 28 128/64 3+ 3+ 4+ 4+

Edema Rt 1+ 2+ 3+ 4+ Leg/foot X Lt 1+ 2+ 3+ 4+ Leg/foot X Other: Edema on both arms and on his scrotum Blood Sugar: _NA Amt: __119

Coverage: ______________________

Blood Transfusion: ___ NA Consent Present: ____Order Type: _______ Unit(s) _____________ Checked by 2 licensed personnel: _____ Therapeutic Measures: ___Turning pt q2hrs and performing ROM Discharge and Teaching Needs: ___________________________________________________ ASSESSMENT: General appearance: __both hands and legs are contracted, stiff neck, confined in bed, very dried skin, awake, unresponsive, stomach extended, edema on both hands, legs and his scrotum, two wound vacs, foley, total immobile. Self Perception: __

Clinical Review

Psychosocial Activity/Interest: __None Sleep: __mostly at night Rest: __all the time

Medications including IV drips: Allergies: __denied allergy Medications Date Name of Drug /IV Ordered Fluid 6/25/2011 Dorzolamide HCLTrusopt Dose/Frequency Times (Days if will Route
expire)

Purpose for Client To treat high pressure inside the eye due to glaucoma (open angle-type) or other eye diseases Used to treat high pressure inside the

Home Medication
(Enter yes or No)

Ophthalmic

2 times per day

No

6/25/2011

LatanoprostXalatan

Ophthalmic

At bedtime

No

Clinical Review eye due to glaucoma (open angle type) or other eye diseases (e.g., ocular hypertensio 6/25/2011 Tamsulosin HCLFlomax Via G-tube At bedtime n). Used in men to treat the symptoms of an enlarged 6/25/2011 Miralax Powder Via G-tube 2 time per day prostate. Used to treat occasional 6/25/2011 Metoclopramide HCL-Regan Via G-tube Before meals+bed constipation Used to Yes treat certain conditions Yes Yes

Clinical Review of the stomach and 6/25/2011 Hydralazine HCL Via G-tube 3 times per day intestines. Used to treat high blood 6/25/2011 Carvedilol-Coreg Via G-tube 2times per day pressure Used to treat high blood pressure and heart 6/25/2011 Doxazosin MesylateVia G-tube At bedtime failure Used alone or in combinatio n with other drugs to treat hypertensio 6/25/2011 Albuterol Sol Nebulization Q6hrs n Used to treat and to No yes Yes Yes

Clinical Review prevent bronchospa 6/26/2011 Fluconazolediflucan Oral daily sm Used to prevent and treat a variety of fungal and yeast infections. Used with or without other medications to treat high blood pressure Used to treat gout and certain types of kidney stones Used with other drugs to treat a certain type of stomach and intestinal ulcer (peptic No

6/26/2011

Amlodipine Besylate-Norvasc

Via G-tube

Yes

6/26/2011

Allopurinol

Via G-tube

daily

Yes

6/26/2011

GlycopyrrolateRobinul

Via G-tube

3time per day

Yea

Clinical Review ulcer). Used to treat or prevent low blood levels of iron Used to treat constipation Used to treat a wide variety of bacterial infections Used to improve digestion and restore normal flora. Used along with a proper diet to help bad cholesterol and fats Used to treat a severe intestinal condition known as

6/26/2011

Ferrous Sulfate

Via G-tube

daily

Yes

6/27/2011 6/28/2011

Lactulose Doripenem Monohydrate/Sodi um Chloride 0.9% Saccharomyces Boulardii-Florastor

Via G-tube IV

Q8hrs Q8hrs

Yes No

6/28/2011

Oral

4 times per day

No

6/28/2011

Simvastatin-Zocor

Oral

At bedtime

No

6/29/2011

Vancomycin HCL/Dextrose 5%water

IV

Q24hrs

No

Clinical Review Clostridium difficileassociated diarrhea. Used along with a proper diet and exercise program to control high blood sugar Used to prevent blood clot formation Used to treat a variety of infections Purpose for Client Used for a short time to treat occasional 6/25/2011 Alum-Mag hydroxideOral prn constipation Used to treat the symptoms of too No

7/01/2011

Insulin Glargine

Subcutaneous

At bedtime

No

7/02/2011

Heparin Sodium

Subcutaneous

Q12hrs

Yes

7/04/2011

Metronidazole

Oral

3 times per day

No

Prn Medications: Date Name of Drug /IV Ordered Fluid 6/25/2011 Magnesium hydroxide 15%

Dose/Frequency Times (Days if will Route


expire)

Home Medication
(Enter yes or No)

Oral

prn

No

Clinical Review simethiconeMylanta much stomach acid such as stomach upset, heartburn, and 6/25/2011 Trimethobenzamide IV HCL-Tigan Q6hrs prn acid indigestion. Used to treat nausea and vomiting that can occur following surgery or with certain stomach/intestinal problems (e.g., 6/25/2011 Acetaminophen Oral Q6hrs prn gastroenteritis). Used to temporarily treat cough, stuffy nose, body aches, and other symptoms (e.g., fever, headache, sore throat) caused by the No No

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Clinical Review common cold, flu, or other breathing illnesses (e.g., sinusitis, 6/25/2011 Nitroglycerin Sublingual Prn bronchitis). Used before physical activities (such as exercise, sexual activity) to prevent chest pain (angina) in people with a certain heart condition (coronary artery disease). Used to decrease saliva and phlegm and to control stomach/intestinal spasms Used to treat occasional constipation Used for a short time to treat people who have trouble falling asleep. Used to treat diabetes mellitus No

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6/25/2011

Atropine SulfateAtropisol

IV

prn

No

6/25/2011 6/25/2011

Docusate SodiumColace Zaleplon-sonata

Oral Oral

prn Bedtime prn

No No

6/25/2011

Insulin Reg

Subcutaneous

prn

No

Clinical Review

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Doctors Orders Labs NOTE: References range from clinical site to clinical site Name of Test Normal CBC c /Diff Ranges WBC RBC Hgb Hct MCV MCH MCHC RDW Platelets Bands (stab) Immunatureaeutroph) Segs Mature neutrophils Lymphs Mono Eosins Baso 4.8 10.8 4.2 5.4 (F) 4.6 6.2 (M) 12 16 (F) 14 18 (M) 37 47 (F) 42 52 (M) 82 - 92 27 31 32 36 12.5 14.5 140 440 5 11 36 - 66 24 44 35 0-3 0 0.75 7/7 7/7 7/7 7/7 7/7 79.5 8.8 8.9H 2.3N 0.5N Rationale For Test Order First date of results Results/ Interpretation Current date of results 7/7 7/7 7/7 7/7 7/7 7/7 7/7 7/7 7/7 Results/ Interpretation 9.4N 3.08L 8.5L 25.8L 83.6N 27.6N 33.1N 15.7H 339N

Clinical Review CULTURES: Date: ___7/7/11 Source: ____Wound Result: ____ESBL (Extended Spectrum Beta Lactamases)

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Date: _____________ Source: ______________________ Result: ______________________

Doctors Orders contd Labs


Name of Test Normal Ranges Rationale For Test First date of results Results/ Interpretation Current date of results Results/ Interpretation

ELECTROLYTES Sodium (Na) 135 158 Potassium 3.5 5 (K) Chloride 95 106 (CL) Carbon 22 30 dioxide CO2 Anion Gap 7 16 Complete Metabolic Profile BUN 7 16 Creatinine 0.5 1.5 Glucose 70 110 Calcium 8.5 10.5 Alk Phos 38 - 126 Tot 0.2 1.3

7/7 7/7 7/7 7/7 7/7 7/7 7/7 7/7 7/7 7/7 7/7

138N 5.3H 110H 22N 6L 43H 1.08N 65L 8.6N 121N 0.8N

Clinical Review Billirubin AST/SGOT T. Protein Albumin T. Globulins A/G Ratio Bun/Creat. BNP Name of Test

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12 - 45 68 3.5 5 1.9 3.6 1.1 2.1 12 20 < 100 Normal Ranges Rationale First date for Test of results

7/7 7/7 7/7 7/7 7/7 7/7 Results/ Current Interpretation date of results 7/7 7/7 7/7 7/7 7/7 7/7

30N 5.9L 2.5L 3.4N 0.7L 40H Results/ Interpretation 121N 30N 0.8N 2.5L <16N

HEPATIC FUNCTION Alk Phos 3.8 126 AST/SGOT 12 49 Bili 0.2 1.3 Bili Direct 01 Albumin 3.5 5 ALT/SGPT 11- 66 LIPID PROFILE Cholesterol 120 200 Triglycerides 20 200 HDL 39 96 LDL 74 174 HDL/Chol % < 4.5 Doctors Orders contd Labs
Name of Test Normal Ranges Rational for Test First date of results Results/ Interpretation

Current date of results

Results/ Interpretation

Cardiac Enzymes CCK 30 135 CKMB 0 10

Clinical Review MB Index 05 Troponin Blood Drug Levels Digoxin PI/ INR 2.5 3.5 X Control APTT 1.5 0 2.5 X Control Amylase Fibrin Platelet count B. T. Other Name of Test URINALYSIS Color Ph Sp. Gravity Protein Glucose Ketones Nitrites Leukocytes Microscopic Sediment Crystals Casts WBC RBC ABGs Normal Ranges Rationale First for Test date of results Results/ Current Interpretation date of results Results/ Interpretation

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4.3 8 1.001 1.040 Neg. Neg. Neg. Neg. Neg.

<45 <2-3

Clinical Review Ph PCO2 PO2 HCO3 O2


Name of Test

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7.35 7.45 35 45 80 100 22 27 98 - 100


Normal Ranges Rationale for Test First date of results Results/ Interpretation Current date of results Results/ Interpretation

Doctors Orders contd Labs

THYROID FUNCTION T4 4.5 12 TSH 0.38 4.70 COAGULATION Pt 9 13 Inr APTT 20 - 34 Doctors Orders contd
Name of Test Normal Ranges Rationale for Test First date of results Results/ Interpretation Current date of results Results/ Interpretation

OTHER (not included in above): Folate OTHER (not included in above):

7/7

19.0

DIAGNOSTIC STUDIES: X-ray:

Type:

Date:

Clinical Review Impression: X-ray Impression: Scan: Impression: Cardiac: Impression: Type: Date: Type: Date: Type: Date:

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CONSULTS: (Be Specific in Descriptions: Respiratory: ___Respiratory therapist for respiratory treatment prn Physical Therapy: __Physical therapist for assistant with physical mobility three times a week. Occupational Therapy: ___occupational therapist for assistant with activities of daily living three times per week. Cardiac: ___N/A

Clinical Review Renal: ___Dialysis Nurse for dialysis treatment Neurology: ___N/A Surgical: __N/A Infectious Disease: ___Wound Nurse to assist with wound healing and to control the wound infection. Extended Spectrum Beta Lactamases (ESBL) Social Services: ____Social workers offer a broad range of services, from emotional support to referrals for community resources. Patient was scheduled to meet with a social worker before discharge. Other: ________________________________________________________________________

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ISOLATION: Type: ___contact Purpose: ___ ESBL of the wound. Extended-spectrum beta-lactamases (ESBL) are enzymes that confer resistance to most beta-lactam antibiotics, including penicillins, cephalosporins, and the monobactam aztreonam. Complete Part 1 Now that you have collected data prioritize the Nursing Diagnoses: #1Nursing Diagnosis: ___Body image, disturbed Related/To: ___body contracture and wounds. As Evidenced by: __pts upper and lower extremities contracture and has two wound vacs including six other open wounds.

Clinical Review

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#2 Nsg. Diag.: ___ Breathing pattern, ineffective R/T: ___abnormal breathing rate (respiration of 28beats/min) AEB: ___pt labor breathing with puff lip on exhaling

#3 Nsg. Diag.: ___Communication: impaired, verbal R/T: ___inability to verbalize and communicates. AEB: ___Patient communicate only by sign language. #4 Nsg. Diag.: ___Diarrhea R/T: ___tube feeding AEB: ___Patient voided over 650mL of stool within a period of 8hours.

#5 Nsg. Diag.: ____Mobility: Bed, impaired R/T: ___contracture of the upper and lower extremities AEB: ___patients inability to get up from the bed without assistance (bed confinement)

Clinical Review

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PATIENT/FAMILY TEACHING PLAN


Indiana Dabney University Willie B. Thurmond School of Nursing

A. Assessment (Include additional data not previously included, that supports the need for teaching for this patient/family): bed sore, fluid & electrolyte imbalance through diaphoresis, wound drainage, consistent diarrhea, and medication. B. Nursing Diagnosis: Knowledge deficit related to bed sore (failure to turn patient q2hrs) and medication (uses, side effects, contraindication, and action) C. Patient/family teaching goal and outcome criteria: 1. Goal: Patient will be free from bed sore throughout hospitalization. Patient will signal no pain sensation 15minutes after pain medication administration through sign language. 2. Outcome criteria: Patient is free from bed sore by the end of hospitalization. Goal was met. Patient was able to signal no pain on a scale of 0/10, 15minutes after medication administration through sign language. Content of teaching (what are you going to teach): Teach the importance of turning patient q2hrs to prevent bed sore from occurring. Teach the need to take pain medication when needed. Strategies: (How are you going about it) Encourage patient not to signal for pain medication when needed. Enforce turn every 2hr roster for caregivers.

B. Plan 1.

2.

Clinical Review

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C. Intervention and evaluation (What did you actually do & what was the response of the patient family?): Teach patient the need for medication and encourage patient not to hesitate to signal for medication when needed. Goal was met. Consistently reminding caregivers to turn patient every 2 hours. Goal was met. DISCHARGE PLAN
Indiana Dabney University Willie B. Thurmond School of Nursing

By the time of discharge the patient/family will be able to verbalize and/or demonstrate: 1. how to turn patient every 2 hour to promote skin intact. 2. signal (sign language)for medication when needed. 3. unlabored breathing pattern. 4. movement of the upper and lower extremities by active range of motion. 5. how to care for wound.