lOMoAR cPSD| 56342273
Criteria / Section Pre S NI U Comments
PRE-CLINICAL (Complete before patient care)
I. Baseline Information
1. Demographics - complete & accurate
II. Information from Chart
1. Chief Complaint
2. History of Present Illness
3. Past Medical History & Chronic health issues
III. Focus of Care
1. Expect to see when enter room
2. Important assessments
3. How do you know pt. is improving?
4. Potential complications and interventions
IV. Considerations for Care
1. Diet /Nutritional issues - rationale *
2. Activity
V. Labs & Diagnostics
1. Labs accurate & interpreted (critical/abnormal only) *
2. Diagnostics accurate & interpreted (critical/abnormal only)
VI. Medications *
1. PO, IM, Subcut, topical, instillations
2. Other medications (IV, etc.) - NOT given by student
POST- CLINICAL (Complete after patient care)
VII. Patient Assessment Tools (during & post clinical)
1. Physical Assessment X
2. Psychosocial Assessment * X
VIII. Research and Mapping
1. Priority medical &/or surgical diagnosis X
2. Pathophysiology of the priority diagnosis * X
3. Risk Factors X
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4. All potential complications X
5. Medications specific to the pathophysiology X
6. Labs and Diagnostics X
7. Signs and Symptoms X
8. Draws arrows to connect concepts X
IX. Priority Nursing Care Plan * all data complete, accurate & referenced
1. Priority Problem/NANDA* X
2. Signs & Symptoms X
3. Main and/or contributing causes X
4. Expected Outcomes * X
5. Nursing Interventions with rationale * X
6. Collaborative/Teaching Intervention with rationale * X
7. Evaluation/modification * X
X. Additional Forms
1. SPICES Assessment Tool (every pt. over 65) X
2. Clinical Organizational Tool
3. Reflection Tool X
4. Reference Page (APA format) X
Pre = Must be completed as pre-clinical S = Satisfactory NI = Needs Improvement U = Unsatisfactory
* Indicates all areas where specific references are required.
Baseline information referenced from chart, & all
other information referenced in APA format from appropriate texts. Attach this page to the front of every
Preclinical Work up & Care Plan.
Rev: 1/20
Preclinical Work-Up Baseline
Student: Elena Atencio Unit: 1600 Date of Care: 02/10/2022
I. Baseline Information - Demographics
Pt. Initials MH Room # ___ Sex/Age 72 Code Status Full A.D. N/A
Ht.168 cm. Wt.78 kg ALLERGIES (& response to if known): NKA
Admitting Diagnosis(es) Pneumonia
Actual (Current) Diagnosis Pneumonia Date of Admission 02/01/22
Current Surgery(s) Date(s)
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Isolation Precautions droplet Fall Risk Precautions ________
Erikson’s Developmental Level Integrity vs. Despair
Culture/Ethnicity _Hispanic/Catholic_____________________________
II. Information from chart:
1. Chief Complaint (Reason for Hospitalization): Dyspnea on exertion, malaise, fever, shaking chills, cough with
rust-colored sputum
2. History of Present Illness (HPI) Tell the patient’s story about this illness including the data from the date of
admission to present day:
Mrs. Hernandez was experiencing symptoms of dry cough, fever, and malaise, and was diagnosed with
influenza 10 days prior to admission. Her symptoms got progressively worse, and yesterday she had a temperature
of 38.4 °C (101.2 °F), shaking, chills, and a productive cough of rust-colored sputum. Her primary care provider
saw her yesterday and decided to admit her for treatment of pneumonia.
Started on antibiotics after a sputum specimen for gram stain culture was obtained. Result is pending.
1. Past Medical History (PMH) Bullet point:
● Hypertension
● Surgeries: Appendectomy at the age of 8 years
● History of smoking
III. Focus of Care (Think like a nurse, bullet point your answers):
Based on your preclinical research, what do you expect this patient to look like in terms of their diagnosis
and condition when you walk into the room at the start of the shift?
Patient is cyanotic, fatigued, respirations are labored, dyspnea and desaturation on exertion, she speaks in
short sentences with bronchophony and egophony, fine or coarse crackles on auscultation, tachypnea, use of
accessory muscles, increased tactile fremitus
What are the priority assessments to make, including labs and diagnostics?
● Perform focused respiratory assessment including gathering past medical hx information on hx of smoking,
respiratory function, physical activity, past respiratory infections and cardiac diseases.
● Assess patient’s knowledge on safety of oxygen therapy
● Assess the patient3Updated
for signsSpand
22 symptoms of ineffective breathing by monitoring her breathing pattern:
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, lOMoAR cPSD| 56342273
depth, rhythm, rate.
● Auscultate breath sounds, as indicated by the patient's condition.
● Monitor respiratory rate, depth, and effort. ● Monitor heart rate and rhythm, as ordered.
● Monitor pulse oximetry, as ordered.
● Monitor arterial blood gas levels, CBC, CMP, sputum culture
3. What will tell you if the patient is improving?
Pulse Oximetry is wnl >95% on Room Air
Afebrile with VS wnl
No SOB, no c/o chest pain
Unlabored breathing
Lung sounds clear x 4 lobes,
RR is wnl, no use of accessory muscles noted
Laboratory results are wnl: ABG's, CBC, CMP
Patient reports cough subsided, sputum is clear or absent
4.
Potential Complications: include assessments, and Interventions to Prevent the Complications
how would you recognize it (List as many as
applicable)
4Updated Sp 22
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Criteria / Section Pre S NI U Comments
PRE-CLINICAL (Complete before patient care)
I. Baseline Information
1. Demographics - complete & accurate
II. Information from Chart
1. Chief Complaint
2. History of Present Illness
3. Past Medical History & Chronic health issues
III. Focus of Care
1. Expect to see when enter room
2. Important assessments
3. How do you know pt. is improving?
4. Potential complications and interventions
IV. Considerations for Care
1. Diet /Nutritional issues - rationale *
2. Activity
V. Labs & Diagnostics
1. Labs accurate & interpreted (critical/abnormal only) *
2. Diagnostics accurate & interpreted (critical/abnormal only)
VI. Medications *
1. PO, IM, Subcut, topical, instillations
2. Other medications (IV, etc.) - NOT given by student
POST- CLINICAL (Complete after patient care)
VII. Patient Assessment Tools (during & post clinical)
1. Physical Assessment X
2. Psychosocial Assessment * X
VIII. Research and Mapping
1. Priority medical &/or surgical diagnosis X
2. Pathophysiology of the priority diagnosis * X
3. Risk Factors X
1Updated Sp 22
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4. All potential complications X
5. Medications specific to the pathophysiology X
6. Labs and Diagnostics X
7. Signs and Symptoms X
8. Draws arrows to connect concepts X
IX. Priority Nursing Care Plan * all data complete, accurate & referenced
1. Priority Problem/NANDA* X
2. Signs & Symptoms X
3. Main and/or contributing causes X
4. Expected Outcomes * X
5. Nursing Interventions with rationale * X
6. Collaborative/Teaching Intervention with rationale * X
7. Evaluation/modification * X
X. Additional Forms
1. SPICES Assessment Tool (every pt. over 65) X
2. Clinical Organizational Tool
3. Reflection Tool X
4. Reference Page (APA format) X
Pre = Must be completed as pre-clinical S = Satisfactory NI = Needs Improvement U = Unsatisfactory
* Indicates all areas where specific references are required.
Baseline information referenced from chart, & all
other information referenced in APA format from appropriate texts. Attach this page to the front of every
Preclinical Work up & Care Plan.
Rev: 1/20
Preclinical Work-Up Baseline
Student: Elena Atencio Unit: 1600 Date of Care: 02/10/2022
I. Baseline Information - Demographics
Pt. Initials MH Room # ___ Sex/Age 72 Code Status Full A.D. N/A
Ht.168 cm. Wt.78 kg ALLERGIES (& response to if known): NKA
Admitting Diagnosis(es) Pneumonia
Actual (Current) Diagnosis Pneumonia Date of Admission 02/01/22
Current Surgery(s) Date(s)
2Updated Sp 22
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Isolation Precautions droplet Fall Risk Precautions ________
Erikson’s Developmental Level Integrity vs. Despair
Culture/Ethnicity _Hispanic/Catholic_____________________________
II. Information from chart:
1. Chief Complaint (Reason for Hospitalization): Dyspnea on exertion, malaise, fever, shaking chills, cough with
rust-colored sputum
2. History of Present Illness (HPI) Tell the patient’s story about this illness including the data from the date of
admission to present day:
Mrs. Hernandez was experiencing symptoms of dry cough, fever, and malaise, and was diagnosed with
influenza 10 days prior to admission. Her symptoms got progressively worse, and yesterday she had a temperature
of 38.4 °C (101.2 °F), shaking, chills, and a productive cough of rust-colored sputum. Her primary care provider
saw her yesterday and decided to admit her for treatment of pneumonia.
Started on antibiotics after a sputum specimen for gram stain culture was obtained. Result is pending.
1. Past Medical History (PMH) Bullet point:
● Hypertension
● Surgeries: Appendectomy at the age of 8 years
● History of smoking
III. Focus of Care (Think like a nurse, bullet point your answers):
Based on your preclinical research, what do you expect this patient to look like in terms of their diagnosis
and condition when you walk into the room at the start of the shift?
Patient is cyanotic, fatigued, respirations are labored, dyspnea and desaturation on exertion, she speaks in
short sentences with bronchophony and egophony, fine or coarse crackles on auscultation, tachypnea, use of
accessory muscles, increased tactile fremitus
What are the priority assessments to make, including labs and diagnostics?
● Perform focused respiratory assessment including gathering past medical hx information on hx of smoking,
respiratory function, physical activity, past respiratory infections and cardiac diseases.
● Assess patient’s knowledge on safety of oxygen therapy
● Assess the patient3Updated
for signsSpand
22 symptoms of ineffective breathing by monitoring her breathing pattern:
Downloaded by Legit Actualexams
()
, lOMoAR cPSD| 56342273
depth, rhythm, rate.
● Auscultate breath sounds, as indicated by the patient's condition.
● Monitor respiratory rate, depth, and effort. ● Monitor heart rate and rhythm, as ordered.
● Monitor pulse oximetry, as ordered.
● Monitor arterial blood gas levels, CBC, CMP, sputum culture
3. What will tell you if the patient is improving?
Pulse Oximetry is wnl >95% on Room Air
Afebrile with VS wnl
No SOB, no c/o chest pain
Unlabored breathing
Lung sounds clear x 4 lobes,
RR is wnl, no use of accessory muscles noted
Laboratory results are wnl: ABG's, CBC, CMP
Patient reports cough subsided, sputum is clear or absent
4.
Potential Complications: include assessments, and Interventions to Prevent the Complications
how would you recognize it (List as many as
applicable)
4Updated Sp 22
Downloaded by Legit Actualexams ()
