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PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

Student Name: Week: Dates of Care:
Patient Initials

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M.R

 

Sex F

Age 62

Room 616

Admitting Date 5/27/2022

Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

Right knee Arthrotomy

Right knee patella revision

 

Attending physician/Treatment team:

Frisch, Nilesardo, Maya, long K Ham

 

Consults:

Hospitalist group, Md

Present Diagnosis: (Why patient is currently in the hospital)

· Left wrist pain

· Right knee pain

· Moderate episode of recurrent major depressive disorder (HCC)

· Panic disorder with agoraphobia, mild agoraphobic avoidance, and mild panic attacks

· Numbness and tingling in both hands

· Mass of left wrist

 

ER Management: (if applicable)

Total knee replacement

Right knee patella revision

 

Allergies:

Niacin and Related

 

Code Status: Full code Isolation: (type and reason) None

Admission Height:

170.2 cm (5’7)

 

Admission Weight: 124.7 lg (275 lb)

Arm Band Location (colors & reasons)

 

Communication needs: (verbal, nonverbal, barriers, languages)

No problem with communications. Can speak English and there were no language barriers.

 

Past Medical History: (pertinent & how managed)

· Anxiety

· Arthritis (pt states osteoarthritis)

· Asthma

· Depression

· Diabetes mellitus (HCC)

· Diabetes mellitus, type 2 (HCC)

· General weakness 2 to S/P. Lt. TKR (total knee replacement) using cement

· GERD (gastroesophageal reflux disease)

· Hypertension

· Migrains

· PONV (postoperative nausea and vomiting)

· Right knee pain

· Stroke (HCC) TIA x2 in 2011 and 2012 with LUE weakness

 

Significant Events during this hospitalization but not during this clinical time: (include the date, event and outcome)

A 62-year-old Hispanic female with a history as noted below presents for the elective procedure(s):

The patient states did well after bilateral TKAs in 2014 but fell on R knee 2-3 months ago and has had patellar pain since that time, especially with weight-bearing, flexion, and turning Saw their care provider with concern for loosening of the prosthesis. No recent or other UTI/URI sx, chest pain, shortness of breath, orthopnea, PND, dizziness, syncope, palpitations, LE pain/swelling, fevers/chills, headaches, confusion, numbness/tingling/weakness, speech/swallowing/vision changes, back pain, abdominal pain, nausea, vomiting, diarrhea, constipation, melena/hematochezia, or COVID symptoms.

 

Tests/Treatments/Interventions impacting clinical day’s care (include current orders)

 

Assessments and interventions: (Include all pertinent data)

Vital signs: (2 sets per day)

Time

0942

1322

T

98.3

98.2

P

79

62

R

18

18

B/P

143/63

149/77

Time

1355

1425

T

98.2

98.5

P

94

88

R

18

18

B/P

154/72

170/69

 

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)

 

Respiratory:

02 modalities:

02 Saturation:

Suction:

Resp Rx’s:

Trach:

Chest Tubes:

Pertinent Labs/Test:

Assessments/Interventions: (Lung sounds, cough, sputum, SOB)

 

Neurosensory:

Neuro checks:

Alert & Orientated:

Follows commands:

Speech Comprehensible:

Pertinent Labs/Test:

Assessments/Interventions:

(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)

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

 

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)

 

Pain:

Pain score:

Assessments/Interventions:

(scale used, location, duration, intensity, character, exacerbation, relief, interventions)

 

Vascular Access: (IV site)

Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)

 

Gyn:

Gravida/Para:

LMP:

Last Pap:

Breast exam:

Pertinent Labs/Test

Assessment/Interventions: (bleeding, discharge)

 

Post-operative /procedural:

Assessments/Interventions:

(immediate post procedure care)

 

Safety:

Call light:

Bed Rails:

Bed alarms:

Fall risk:

Assistive Devices:

Sitter use:

Restraints (type, duration & reason):

Assessment/Interventions (modifications to room, environment, Patient)

 

Advance Directives/Ethical considerations:

DPOA:

Hospice:

 

Pertinent Data (Labs, X-rays, Etc.)

Results

Normal Lab Values

Significance to your patient

WBC

10.0

RBC

4.20

HGB

12.4

HCT

36.4

MCV

86.7

MCH

29.5

MCHC

34.0

Platelets

12.9

RDW

198

MPV

7.3

PT

N/A

INR

N/A

APTT

N/A

Glucose

188

BUN

17

Creatinine

0.75

Sodium

138

Potassium

3.9

Cloride

103

Calcium

9.0

T Protein

N/A

Albumin

N/A

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

N/A

CK

N/A

CK-MB

N/A

Troponin I

N/A

Myoglobin

N/A

LDI

N/A

Urinalysis

N/A

Color

N/A

Character

N/A

Spec. Grav.

N/A

pH

N/A

Protein

N/A

Glucose

165 (H)

Acetone

N/A

Bilirubin

N/A

Blood

N/A

Nitr

N/A

Urobili

N/A

RBC

N/A

WBC

N/A

Epithelium

N/A

Urine Culture

N/A

Chest X-ray

N/A

MRI

N/A

CT Scan

N/A

Others test:

N/A

 

Psycho/Social: Assessment/Interventions:(mental illness, social history, living arrangements, primary caregiver, substance abuse, maternal/infant bonding, family dynamics)

 

Cultural/Spiritual needs: Assessment/Interventions: (religious preference, adaptations & modifications, end of life decisions)

Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient:

 

Current overall plan of care: (A short statement that summarizes the anticipated plan of care)

 

Discharge plans and needs:

 

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.

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.

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

Morphine PF

Injection

 

 

4mg Intravenous Every 4hrs PRN Severe pain breakthrough pain  

 

Aluminum & Magnesium hydroxide (Maalox plus)

 

 

15ml Oral Every 6hrs PRN Indigestion  

 

Docusate sodium (Colace) capsule

 

 

100 mg Oral 2 times daily Constipation  

 

Enoxaparin

(Loveriox)

 

 

40mg Injection Subcutaner Every 12 hr  

 

 

Gabapentin

(Neurontin)

 

 

300 mg Oral Every 8 hrs  

 

 

Ibuprofen (Motrin)

 

 

600mg Oral Nightly PRN  

 

 

Ketorolac

(TORADOL)

Injection

 

 

15mg Intravenous Every 6hrs  

 

 

Oxycodone

(Roxicodone)

 

 

10mg Oral Every 4hrs PRN Immediate release, Severe pain  

 

Hydroxyzine (ATARAX)

 

 

25mg Oral Nightly PRN Itching, sleep  

 

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

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.

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