CLINICAL ASSESSMENT Jody Monks 03.13.

12 Student Name__________________________________________________________ Date_______________________ S (Situation) Patients Report Age/Gender 79/Male Admission date 03.12.12 Code status FULL CODE Allergies NKA V/SR18, SPo2 97%
Room Air, P80, T96.6, BP115/55

B (Background) Past Health History Medical Chief Complaint Diagnosis: Weakness Past Medical Surgeries: Amputation of Hx: right big toe PTSD, 1997. Manic/Depressive,
Bi-Polar Disorder, BPH COPD.

A (Assessment) Patient Data Head-to-toe assessment** Patient is A&Ox3. Pupils are PERRLA. Oral mucosa is moist/pink & intact. Patient's speech is clear and he responds appropriately to conversation. Patient reports pain as a 5 on 1-10 scale. Skin: skin is warm/dry to touch color elsewhere on of the skin is normal for age/ethnicity. Capillary refill >3 seconds. PMI 84 with audible S1S2Lung sounds are clear bilaterally in upper & lower lobes. Bowel sounds are normoactive in all quadrants with no tenderness, or distention in the abdomen. Patient is continent of bowel & bladder. Patient wheelchair and full assistance for mobility due to overall weakness. Patient's last bowel movement was today (03.13.12). Stool was formed, moderate amount. Patient states that he has "had some prostate trouble in the past" but could not recall specifically and that it affects his ability to maintain a urine stream. Continued on reference page, out of room...

R (Recommendation) Plan & Action Assess possible relationship between patients weakness and medications. Assess patient's dietary/exercise habits at home. Educate the client about the importance of proper diet and exercise to increase metabolism/energy levels and maintain muscle strength.

Labs (indicate ; use the back of page if needed): See labs page Diagnostic Test(s): See Labs

Diet: Regular Diet Current Wt/Ht/BMI HT 71", WT153, BMI 21.3 Braden score: 15 Fall score: Isolation: No

Home Meds (name/dosage/route/time/indicatio n) See Medication Cards

Religious Beliefs: Athiest 8 Spiritual or cultural implications for care: None noted at this time

Not Measured I________________ clinical day

Not Measured O__________________________

*Refer to assessment reference/text (Chapter 3 of course text)

Narrative Documentation
Date Time
1400 1500
1600

Documentation
introduced myself to my patients and asked permission to be their student nurse, both clients agreed. Assisted patient in ambulating to the restroom. Assisted the RN in administering PRN medication
Transported 3 patients from 4 west to XRAY/CT

03.13.12
03.13.12
03.13.12

03.13.12
03.13.12

1700
1800

Assisted RN in educating client about proper diet and exercise and meeting the bodies needs.
Watched physician scope a patients stomach.

03.13.12
03.13.12

1900
2000

Assisted my patient in shaving

Assisted a post op patient in ambulating.

Medical Diagnosis Pathophysiology Student: Jody

Monks

Date: 03.13.12

Medical Diagnosis Pathophysiology Definition:

COPD is a broad term for the classification of several irreversible lung disease associated with dyspnea upon
exertion and a reduction of airflow into and out of the lungs. It also includes narrowing of the airways, damage

to the lungs and other supportive tissues, hyperactivity of the lungs, dysfunction of the cilia in the airways,
and constant damage of the alveolar walls.

Causes:
Cigarrette smoking is the leading cause of COPD. Long term exposure to other lung irritants including
pollution, chemical fumes, and even extreme dust.

Symptoms:

Chromic cough, SOB, frequent respiratory infections, increased sputum production.

Treatments:
If you are a smoker and have been diagnosed, stop smoking. Medication treatments include: bronchodilators,

inhaled steroids, antibiotics, oxygen therapy, and pulmonary rehabilitation. Surgical treatments can include l
lung volume reduction surgery and even lung transplant.

Medical Diagnosis Pathophysiology SUMMARY OF CARE List three possible complications of the medical diagnosis that might be seen with this patient: 1) Chronic infections 2) Hypertension 3) Depression List signs and symptoms you would see with each complication: Complication #1:
increased amount of sputum, change in the color of sputum, tightness/ chest pain.

Complication #2:
dull headaches, nosebleeds, dizzy spells, insomnia, or increased sleepiness

Complication #3:
Loss of interest in activites previously enjoyed.

List interventions you would take to prevent the three complications: Complication #1:

Complication #2:

Complication #3:

List the developmental stage you would place this client using Ericksons stages of development:

List the supporting assessment information used in placing the client in this developmental stage:

Other information: Student: Jody

Monks

Source: Diguilio 2007 Date: 03.13.12

LABORATORY TESTS, DIAGNOSTIC TESTS, OR PROCEDURES List all the most recent labs, diagnostic test or procedures. If none is on the chart, list testing that might be done for this admitting diagnosis(es) Name of test or Date Normal Result Client result Previous client result and Nursing implications procedure completed date completed

WBC RBC HGB HCT

03.12.12 03.12.12 03.12.12 03.12.12

4.5-11 4.6-6.2 13-18 40-54

10.6 4.84 16.7 42.3

These were the initial tests performed upon

W/in normal range W/in normal range W/in normal range W/in normal range

MCV
MCH MCHC

03.12.12
03.12.12 03.12.12

80-100
27-33 32-36

90.2
31.8 34.1

patients
admit to the VA hospital

W/in normal range

W/in normal range W/in normal range

Student: Jody

Monks

Date: 03.13.12WBC

NURSING CARE PLAN

Problem #1: ineffective breathing pattern R/T disease process Goal:

Client will demonstrate SpO2 of >/=95% within 2 hours

3 Client Responses to Interventions

Outcome: Client will maintain Sp02 SpO2 of >/=95% throughout hospital stay. 3 Nursing Interventions w/ rationale (cite sources)

1. Elevate head of bed, or have client sit upright in chair. (R) This will promote maximum inspiration and releave pressure on diaphragm. 2. Encourage ambulation as indicated. (R) To increase respiratory muscle strength. 3. Direct client in proper breathing efforts, slow deep breat (R)
Evaluation:

1. Patient states feeling of getting deeper breaths 2. Patient states easier to take deep breaths 3. Patient demonstrates proper breathing technique

to assist client in taking control of situation esp. during anxiety.

Client has maintained 97% Sp02 levels and states eased breathing.
Problem #2: Goal:

Imbalanced nutrition more than body requirements R/T excessive intake in relation to metabolic need. Client will state a desire and readiness to lose weight and change lifestyle within one week.
3 Client Responses to Interventions

Outcome: Client has lost 2lbs in one week. 3 Nursing Interventions w/ rationale (cite sources)

1. Determine client's motivation for weight loss. (R) client is more likely to lose/maintain wt when changing for self not others 2. Set realistic goals for weight loss (R) 3Collaborate with DR/Nutritionist (R) develop and implement
Evaluation:

1. Client states reasons for losing weight. 2. Client sets goal of 1lb/week loss 3. Client asks to speak to nutritionist & physician about weigh loss and diet. comprehensive weight loss program & support.

Client attained desirable body weight with optimal maintenance of health.

Use professional references when citing sources; i.e. text or EBP reference.

Student:

Jody Monks

Date:

03.13.12

NURSING CARE PLAN Problem #3: Sedentary Lifestyle R/T lack interest Goal: Outcome:

Pt conveys understanding of importance of regular exercise to his over all well being w/in 3 days.

Pt. shows interest in & participates in physical activities in one week.

3 Client Responses to Interventions

3 Nursing Interventions w/ rationales (cite sources)

1. Establish a therapeutic relationship w/PT (R) eases client 1. Patient states he is comfortable conversing with the nurse communication and honesty 2. Patient states an understanding of his health situation 2. Council client regarding individual health risk (R) focuses 3. Patient assists in developing a diet and exercise program attn on pts own situation & helps prioritize needs making change manageable. 3. Involve client in developing Exercise plan/goals (R) to meet individual needs/desires/available resources. & increase pt commitment. Evaluation:
Client's physical activities have increased between physician visits..
You need to use professional references when citing sources; i.e. text or EBP reference.

Student:

Jody Monks

Date:

03.13.12

Key Problem # Supporting Data: Concept Map Name: _______________________________ Date: ________________________________

Key Problem # Supporting Data:

Reason for Needing Health Care: Medical Diagnosi/Surgical Pocedure

Weakness COPD/Wea kness

Key Assessment Key Problem # Supporting Data:

See head to toe, info won't fit.

Key Problem # Supporting Data:

Overall long term outcome:

Evaluation:

REFERENCES Ackley, Betty J. (1990). Mosby's Dictionary of Medical Nursing & Health Professions (8th ed.). St Louis: C.V. Mosby Company Digiulio, Keogh, Jackson. (2007). Medical Surgical Nursing Demystified: A Self Teaching Guide. New York: Mcgraw-Hill Keogh, Jim (2010). Nursing Laboratory & Diagnostics Tests Demystified: A Self Teaching Guide. New York: Mcgraw-Hill Louis, Heitkemper, Bucher, Camera. (2011). Medical Surgical Nursing: Assessment and Management of Clinical Problems. 8th ed.

Head to Toe Continued.... Patient has an IV in the right, lower section, TOP-side of the forearm (I'm sure there is better wording for that IV description, it is however escaping me). IV site is CDI. Patients pulses are present and equal in all 4 extremities at +3. Patient's muscle strength is a +3, with a full ROM in all extremities. Patient states that his overall mood is "good," and that his moods have been "normal and stable" for "more than a year."

Student Name:

Jody Monks

Date:

03.13.12

CLINICAL PAPERWORK GRADING TOOL

Clinical Paperwork & Nursing Plan of Care Grading Criteria

Jody Monks Student:____________________________________

Possible Points 3 1 2 Medical Pathophysiology 1 Complications (3) Signs & symptoms of complications Interventions to prevent complications Erickson's Developmental stage with Assessment criteria Lab, Diagnostics, and Procedure Data Medications 3 Final Concept Map Nursing diagnoses complete (4) Supporting data for nursing diagnoses Goals (one for each nursing diagnosis) Outcomes (one for each goal and one overall long term) Nursing Interventions Rationale for intervention complete w/ source cited Client responses to interventions Evaluation of outcomes completed References in APA format Total Points Instructor Grading/Comments: 4 2 2 4 6 3 4 4 2 50 1 1 Earne d Points

03.13.12 Date: _________________

Section of Care Plan Head to Toe Assessment Spiritual & cultural assessment

Comments

1 3 3

Date: