Clinical Worksheet geana
Date: _08/24/2020 Student Name: ___Jackie Griffis_________ Assigned vSim: Sandra Littlefield
Initials: SL Diagnosis: Back pain, HCP: Dr. Who Isolation: None IV Type: Critical Labs: Other Services:
unresolved with Location: None WBC, Metabolic panel,
Age: 36 current medication urinalysis
Fall Risk: No
M/F: F Consults: Fluid/Rate: None Consults Needed:
psychiatrist psychiatrist
Code Status: Length of Stay: D1 Transfer: None
Allergies: Codeine,
Penicillin
Why is your patient in the hospital (Answer in your own words and include the History of present Illness): Admitted for back pain that is not resolved with current
pain medications.
Health History/Comorbidities (that relate to this hospitalization): History of back pain and diagnosis of borderline personality disorder.
Shift Goals/ Patient Education Needs:
1. Teach techniques for coping
2. vitals, labs, and mental health assessment
3. Teach relaxation techniques to deal with pain.
4. Set limits and expectations, remind of consequences.
Path to Discharge: Education of the Pt on medication overdose, Resources for pt to get in to group counseling, one on one counseling with a psychiatrist, teach
non medication therapies/relaxation techniques, teach techniques for coping with stress, anger, and frustration without resorting to violence.
, Path to Death or Injury: Suicide, overdose, harm by others/violence, sexually transmitted disease
Clinical Worksheet (Continue to next page)
Alerts: Management of Care: What needs to be done for this Patient Today?
What are you on alert for with this patient? (Signs & Symptoms)
1. Vitals/auscultation
1.Suicide
2. Educate patient
2.Overdose 3. Labs
3.Aggressive behavior 4. Teach coping strategies
5. Teach relaxation techniques
6. mental health assessment
What Assessments will focus on for this patient? (How will I identify Priorities for Managing the Patient’s Care Today
the above signs &Symptoms?) 1. Minimize attention given to complaining
1. mental health 2. mental health assessment
3. vitals/auscultation
assessment
4. Teach coping and relaxation techniques
2.vitals/auscultation
3. labs
What aspects of the patient care can be Delegated and who can do it?
Counseling-psychiatrist
List Complications may occur related to dx, procedure, comorbidities:
1. Suicide
2. Overdose
Date: _08/24/2020 Student Name: ___Jackie Griffis_________ Assigned vSim: Sandra Littlefield
Initials: SL Diagnosis: Back pain, HCP: Dr. Who Isolation: None IV Type: Critical Labs: Other Services:
unresolved with Location: None WBC, Metabolic panel,
Age: 36 current medication urinalysis
Fall Risk: No
M/F: F Consults: Fluid/Rate: None Consults Needed:
psychiatrist psychiatrist
Code Status: Length of Stay: D1 Transfer: None
Allergies: Codeine,
Penicillin
Why is your patient in the hospital (Answer in your own words and include the History of present Illness): Admitted for back pain that is not resolved with current
pain medications.
Health History/Comorbidities (that relate to this hospitalization): History of back pain and diagnosis of borderline personality disorder.
Shift Goals/ Patient Education Needs:
1. Teach techniques for coping
2. vitals, labs, and mental health assessment
3. Teach relaxation techniques to deal with pain.
4. Set limits and expectations, remind of consequences.
Path to Discharge: Education of the Pt on medication overdose, Resources for pt to get in to group counseling, one on one counseling with a psychiatrist, teach
non medication therapies/relaxation techniques, teach techniques for coping with stress, anger, and frustration without resorting to violence.
, Path to Death or Injury: Suicide, overdose, harm by others/violence, sexually transmitted disease
Clinical Worksheet (Continue to next page)
Alerts: Management of Care: What needs to be done for this Patient Today?
What are you on alert for with this patient? (Signs & Symptoms)
1. Vitals/auscultation
1.Suicide
2. Educate patient
2.Overdose 3. Labs
3.Aggressive behavior 4. Teach coping strategies
5. Teach relaxation techniques
6. mental health assessment
What Assessments will focus on for this patient? (How will I identify Priorities for Managing the Patient’s Care Today
the above signs &Symptoms?) 1. Minimize attention given to complaining
1. mental health 2. mental health assessment
3. vitals/auscultation
assessment
4. Teach coping and relaxation techniques
2.vitals/auscultation
3. labs
What aspects of the patient care can be Delegated and who can do it?
Counseling-psychiatrist
List Complications may occur related to dx, procedure, comorbidities:
1. Suicide
2. Overdose
