NURSING 2349-clinical worksheet module 2

Date: 4/11 Student Name: Breanna Ciatti Clinical Site Instructor: S. Bogenrief Previous Shift Report: Pt is alert and oriented but still confused Client age: 86 Gender: F Height: 5’2” Weight: 111lbs BMI: 20.49 Baseline vitals: BP 132/76 Pulse 98 Resp. 18 Temp.98.1 F Pain Score 4/10 Transfer Status: Assist of 1 Allergies: Sulfamethoxazole, Advil, Aspirin, Latex Code Status: DNR/DNI Occupation: Homemaker Religion: Lutheran Pastoral Care: N/A Marital Status: Married Cultural Background: U.S Primary Language: English Diet/Nutrition: No MSG Activity: Not specified Fall Risk: Yes Use of (type/amount/frequency): Alcohol: None Tobacco (pack years): past use over 50 years ago 1 pack/yr Treatments: Creams (lotions), INR IV/Tubes/Ostomies: N/A Interdisciplinary Cares (OT/PT/RT): PT/OT post op Dressings/Wounds: (type & location) : N/A Oxygen: (delivery method & amount) nasal cannula 1 L/min Dialysis: N/A LAB RESULTS: Why is this lab significant for this client’s condition? If the lab result was abnormal, include what the NURSE needs to monitor for or do related to the abnormal lab result under the significance column. Make sure these are on your Systems Disorder Remediation Template. (Should be in the appropriate location) Date Test Normal Value Client Value Significance 4/1 INR 0.9-1.1 2.34 High # indicates thinning of blood which takes longer to clot and pt is at risk for bleeding. Diagnostic tests: (list X-rays, CT scans, MRIs, ECGs, Ultrasounds, Cardiac Catheterizations, etc.) List the test, the test result, and include an explanation of the significance of the results in relation to the medical treatment, other diagnostics, and nursing considerations/interventions for your client. Make sure these are on your Systems Disorder Remediation Template. (Should be in the appropriate location) Xray of chest 4/7/16 new central congestion and small left effusion with left lower lobe consolidation related to poss. Pneumonia Xray of the left hip 43/16 internal fixation left femoral neck fracture with bolt and short intramedullary rod. Main fracture components are in anatomic alignment. Rasmussen College- Blaine Campus 1 Name_____________________ Date: 4/11/16 Client Initials: ES Student Name: Breanna Ciatti Clinical Site/Unit: TCU ASSESSMENT SUMMARY: To be completed during the clinical day. Date: 4/11/16 Client Initials: ES Student Name: Breanna Ciatti Clinical Site/Unit: TCU ASSESSMENT SUMMARY: To be completed during the clinical day. NEW ASSESSMENT Body System Subjective data-Health History Objective data- (head to toe) Assessment findings Rasmussen College- Blaine Campus 2 Name_____________________ Vital Signs and Pain Level: Sensory: Neurological: Respiratory: Cardiac: Integument: Gastrointestinal : Musculoskeletal : Renal: Endocrine: Immune and hematologic: “my hip is very sore this morning, when I move it’s a sharp shooting pain” “probably a 9/10” “I have four pairs of glasses and none of them work” “Haven’t had a sense of smell in 1,000 years” “My feet are ticklish” “I have delayed reactions to everything” “Not hard to breathe only after I talk a lot- nebs help” “I was diagnosed with allergy induced asthma after my stroke” “I am on medication for a fib” “I do not have any sensations of a fib” “I have very dry skin that’s why I use lotion” “I have the most wonderful stool control in the world” “My muscles are decreasing due to not moving, especially with my surgery” “I have no problems going pee” “I sleep well most of the time” “Overall I’m extremely healthy, I have a ton of allergies but I know how to manage them” Temp- 98.1 F HR- 98 RR- 18 BP- 130/80 Pain Score- 0/10 when resting, 3/10 with movement of hip. PERRLA, alert and oriented x3, Sensory intact, no numbness or paralysis or paresthesia in any body parts, cranial nerves intact Lung sounds clear, nail beds pink S1 and S2 heard; regularly irregular beat, apical pulse matches radial pulse, equal on all sides. No rashes or lesions, hair evenly distributed, eye lashes present. One bruise on left forearm about the size of a dime. No edema Auscultation indicates presence of all quadrants bowel sounds, soft and nontender abdomen Observable unstable gait Urine dark yellow with no odor No swollen lymph nodes Suspected lowered immune system due to surgery and stay in a hospital/ TCU. Date: 4/11/16 Client Initials: ES Student Name: Breanna Ciatti Clinical Site/Unit: TCU Medical Diagnosis(s): Rasmussen College- Blaine Campus 3 Name_____________________ Admitting: 1. Left Hip Fracture Primary Dx (If different than admitting Dx) 1. Left Hip fracture Secondary Dx: 1. Anxiety 2. depression 3. GERD 4. COPD Surgeries: 1. Left Hip (plate and screw) surgery Narrative Note: DATE TIME S- patient states she does not want to use the bathroom because she “does not want to bother the aides” O- Patient only had one glass of water (when administered pills) and drank no extra water throughout the day, patient only had to call the nurse once for toileting assistance A- Anxiety about using the bathroom and asking for help P- Have patient one cup of water every hour and take her to the bathroom every hour I. Devliever a new cup of water every hour II. Make a toiletin