Christopher Parrish Clinical Worksheet

Christopher Parrish Clinical WorksheetClinical Worksheet Date: 05/03/2021 Student Name: Carly Gee Assigned vSim: Christopher Parrish Initials: CP Age: 18 M/F: M Code Status: full Diagnosis: cystic fibrosis Length of Stay: 1 day Allergies: NKA HCP: N/A Consults: nutrition Isolation: Standard Fall Risk: yes Transfer: Stand- by IV Type: N/A Location: N/A Fluid/Rate: NG tube fluid rate 60 mL/hr Critical Labs: Albumin, Creatinine, Protein, Vitamin D Other Services: OT Consults Needed: Dietary Why is your patient in the hospital (Answer in your own words and include the History of present Illness): Patient has been admitted to the hospital after visiting with his PCP due to losing a total of 13.2 pounds and fatigue. Health History/Comorbities (that relate to this hospitalization): Hx of cystic fibrosis since childhood and fatigue. Shift Goals/ Patient Education Needs: 1. Assess vitals 2. Educate pt on intake and output 3. Monitor and record NG tube feedings 4. Educate pt on nutrition Path to Discharge: Help patient get nutritional status back underway without the feeding tube. Explain the importance of proper nutrition and maintaining a proper sleep schedule, as well as monitoring daily weight. Path to Death or Injury: client will neglect diet and will begin to deteriorate due to lack of inadequate nutrition This study source was downloaded by from CourseH on :22:01 GMT -05:00 This study resource was shared via CourseH Clinical Worksheet (Continue to next page) Alerts: What are you on alert for with this patient? (Signs & Symptoms) 1. further weight loss 2. electrolyte imbalance 3. fatigue What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1. Assess intake and daily weights. 2. Assess the skin every 2- 4 hours. 3. Assess patient’s ability to perform ADL’s. List Complications may occur related to dx, procedure, comorbidities: 1. Weight loss r/t malnutrition. 2. Skin breakdown r/t NG tube and being put on bed rest. 3. Fatigue r/t daily activities. What nursing or medical interventions may prevent the above Alert or complications? 1. Making sure patient is educated on the importance of following the proper diet recommended. 2. Making sure patient is educated on properly monitoring daily weights. 3. Assisting the patient with skin care around NG tube while admitted and repositioning the client when possible to prevent bed sores on other areas of the body. 4. Assisting the client with ADL’s as tolerated and educate the patient on how to not over do it once discharged. Management of Care: What needs to be done for this Patient Today? 1.Head to toe assessment. 2. Measuring and recording vital signs every 4 hours. 3. Making sure medication orders are followed, including the feedings for NG tube. 4. Educating the patient on the NG tube and possibility of aspirating, diet and nutrition, input & output, daily weights, and BMI. 5. Monitor labs. 6. Making sure fall precautions are in place and are being followed. Priorities for Managing the Patient’s Care Today 1. Measuring and recording vital signs every 4 hours. 2. Follow the medication orders as well as the feeding orders. 3. Making sure patient is comfortable and not feeling nauseated during feeding. 4. Assisting the client to and from the restroom and providing the proper skin care. What aspects of the patient care can be Delegated and who can do it? The UAP can: measure and record vital signs, assure that fall precautions are in place, assist the patient to and from the restroom if needed. The nurse can: complete H-T assessment, give and record patient’s medication, give and record patient’s tube feedings, educate the patient on nutrition and safety precautions. Provide skin care if needed.