MONA HERNANDEZ CLINICAL WORKSHEET

1-31-2021 Clinical Worksheet Mona Hernandez Date: Student Name: Tracy Jacobs Assigned vSim: Initials: MH Age: 72 M/F: F Code Status: Full Diagnosis: Pneumonia Length of Stay: Allergies: PCN HCP: Consults: Isolation: N/A Fall Risk: Yes Transfer: IV Type: Saline Lock Location: R antecubital vein Fluid/Rate: N/A Critical Labs: WBC: 12.3 (slightly elevated) Other Services: Lab- Blood culture Ultrasound Consults Needed: Respiratory Wound Why is your patient in the hospital (Answer in your own words and include the History of present Illness): Admitted with pneumonia in her right lower lung. Health History/Comorbities (that relate to this hospitalization): 1/2 pack a day smoker, HTN, decreased respiratory status, left leg pain Shift Goals/ Patient Education Needs: 1. Reasses pain 2. Focused assessment on lower extremities 3. Educate patient on coughing, incentive spirometer use,safety, circulation 4. Order labs and ultrasound Path to Discharge: Monitor vitals, no decrease from baseline, pneumonia resolved, cough and incentive spirometer usage and understanding, medication compliance, supplemental oxygen use Path to Death or Injury: Unresolved pneumonia, infection, embolis, septic shock, respiratory failure