Lakeview College of Nursing
Clinical Preparation Assignment
N210 
Student Name: Katey Goodpaster Date: Monday September 19, 2011 Adm. Diagnosis: ___________________________Allergies:Stremtomycin
                                                                                                                                                                                                                                        (5 pts)

Patient Initials: __NM___Age: _79__  Date of Admission: _8/31/11____

Gender:   M     F    Ethnicity: Caucasian__________________________

Education: _High School____________________________________

Where do I live?  House     Farm     Apt.    Asst. Living    (circle one)
                             
             Nursing Home   Other_______________________

I live with_Wife_____________________________________________

Do I have any other family?  Son and grandchildren

__________________________________________________________

Adm. Date: _8/31/11___ Adm. History: (What brought me to hospital?)			
 Wife____________________________________________________

_________________________________________________________ 

_________________________________________________________

_________________________________________________________

I have had these procedures while I have been here: Arterial Line (left radial artery), Fasciotomy, Skin graft, Cath stents, Popliteal to Tibial bypass.

I need help with:   Hygiene      Moving        Eating       Dressing

I need help:         Not at All        Some           Lots             Totally

I have a     DNR       POA       Living Will       None

Activity Level: Cannot get up on own, but can pivot in chair after being relocated there.

Medical History: 

A fib, HTN, Cerbrovascular Accident (due to Intracerebral Hemorrhage) Benign Prostatic Hypertrophy

Surgical History: 

Fasciotomy, Popliteal to Tibial bypass, Catheter Stents, Skin graft, Hernia repair, PICA stent

What equipment am I using?  (Circle all that apply)

Incentive Spirometer     Foley    NG     IV 

  Cast   Splint    Drain     Telemetry     Oxygen

 Chest Tube    Trach      Ostomy       Dressing

TED/SCS      Walker/Crutches      Wheelchair

Other_______________________________    

         I am rating my pain as a    
       ___6____/10     I describe it as:
Sore pain in left leg ____________________
__________________________________________

All data is collected and is recorded using the appropriate terminology.  All sections are complete. 
Any data that is not collected is adequately explained in the blank spaces ie NA or unavailable. 

LAB DATA (List all pertinent/current lab/diagnostic values and highlight which one(s) are abnormal)      			  (1pts)                                                                               
TEST	NORMS	BEFORE	NOW	TEST	NORMS 	BEFORE	NOW	TEST	NORMS	BEFORE	NOW	
WBC				RBC	4.1-5.7		3.20	K				
DIFF: 
Monocytes
Lymphocytes
Neutrophils
Eosiniphils
Basophils	

20-45%		

7.1%	HGB/ HCT	12-18

37-51%		9.6

28.6%	NA				
PT				PLT				CL				
INR				APTT	22-4-35.9		68.9	CA				
GLUCOSE	70-105		134	A1-C				CO2				
CHOLESTROL				BUN				MG				
TRIGLYCERIDE				CREATININE				TSH				
HDL/LDL
				BNP				OTHER				
OTHER
				OTHER				OTHER				
DIAGNOSTICS:  Test & Results                                                                                                                                                                     
   Chest X-Ray:                                                     Other:                                                                         Other:
     
     EKG: 9/15 Post Cardiac Catheter                    Other:                                                                         Other:

PATHOPHYSIOLOGY:  4 parts, answer all 4 questions in a thorough manner using own words and appropriate medical terminology, use additional paper if necessary.

1. Identify the primary disease(s) that will be explained in this paper.     (1pt)

2. Describe the pathology of this disease; include any causative factors/etiologies that can be identified.     (5 pts)

3. Relate the abnormal labs and diagnostics to the disease process.  If all tests are WNL then indicate which values 
    are important to monitor and explain why.       (3 pts)

4. Relate the medications to the disease process or patient situation; include any precautions to be aware of when administering.        (3 pts)

MEDICATIONS:                                                                                                                                                                               (6 pts)                  
List all medications ordered for your patient. Complete first four columns prior to clinical; last column MUST be completed at end of clinical session.
Include PRN meds only if they are administered during clinical time. 
Name, prescribed dose and frequency; plus usual dose and frequency of administration. 	Classification & mechanism of action. [Use your drug reference]	Why is medication ordered for THIS patient?	 Nursing Precautions/ Considerations needed to safely administer this medication. 	 Evaluate medication effectiveness for THIS patient (patient response).	

1.Acetaminophen 325 mg
Every 4 hours PRN

2.Acetaminophen – Codeine 
Every 4 hours PRN

3. Bisacodyl (Dulcolax)
10 mg Daily as needed

4. Cyclobenzaprine (Flexeril) .5 tablet (5 mg)
Every 8 hours PRN

5. Hydrocodone/ acetaminophen (Norco)
325 mg Every 4 hours PRN

6. Magnesium Hydroxide
(Milk of Magnesia)
400 mg/5mL daily as needed

7. Nitroglycerin (Nitrostat) .4 mg every 5 min x 3 PRN

8. Ondansetron (Zofran)
4mg/2mL IV

9.Oxycodone (Percocet)
325 mg tablet every 6 hours PRN

10. Sodium Phosphates (Fleet) 133 mL daily at needed.

1.Analgesic/antipyretics

2. Narcotic analgesic

3.Laxatives

4. Skeletal muscle relaxants

5. Analgesic, Narcotics

6. Laxatives and Cathartics

7. Vasodilators, coronary

8. Antimetic/antivertigo

9. Analgesics/Narcotics

10. Laxatives	
1.Pain

2. Pain

3. Decrease constipation 

4.

5. Pain

6. Constipation 

7. Chest pain

8. Nausea

9. Severe pain

10. Constipation			

Priority Nursing Diagnosis:															                  (2pts)
(Use NANDA format)	
														
What does the patient/client need to accomplish?
GOALS/OUTCOMES

Measurable patient centered goals 
are identified realistic and contain 
time element.  	What can the nurse do to help resolve the problem?
IMPLEMENTATION
Nursing Interventions

Specific nursing actions can easily be linked to the outcomes.  The interventions are realistic and appropriate to the patient's current status.	Why will the nurse do these actions?

SCIENTIFIC RATIONALE
Be sure to include source using APA format

Rationales for each intervention contain comprehensive scientific reasoning that succinctly identifies why the intervention was selected.  Citation is provided.	How did the patient/family respond to the nurse’s actions? 
EVALUATION
Client Response 

Includes all the following: 1.Client’s response to the intervention(s),
 2. Status of goals and outcomes, (ie goal met, in progress or revised) 3. Modifications to the plan of care.	

				
	                             (2pts)                                                                    (2 pts)                                                                                (2 pts)                                                                                    (2 pts)

PHYSICAL ASSESSMENT DATA (collect own data on clinical day)     (Use Taylor Chapter 25 & N201 materials as resources)              (5 pts)
All subjective & objective data is collected and recorded using appropriate terminology. Data not collected or requiring elaboration is explained in the blank spaces.  
Pulse Ox %:
97%	BP:
140/82	Pulse: 
Rate: 96/min
Rhythm: Irregular	Respirations:
Rate: 20/min
Rhythm:Irregular	Temp:
98.1
Route:Oral	Pain:
Rating:      6 /10    Characteristics:  Soreness in LL and chest pain    	Ht: 1.803 M (5’11”)
Wt: 90.266 kg (199lb)	
NEUROLOGICAL: 
 MAE:   Y        N           PERLA:    Y         N
Strength Equal:   Y      N   if no -   Legs   Arms    Both 
Orientation, Mental Status, Speech, Sensory, LOC, 	
Neurological deterioration and mental status changes. Unclear speech, often looked confused during interview

	
MUSCULOSKELETAL: 
Neurovascular status, ROM, Supportive devices/strength

ADL Assistance    Y   N       Fall Risk:    Y   N
Fall Score______________
Activity/Mobility Status:    Independent (up ad lib)     
            Needs assistance with equipment   
            Needs support to stand and walk	
Yes, extremely high fall risk patient. Cannot walk, stand, do much movement on own. Once moved into chair, can slightly pivot. In bed, can help SN roll side during, bed and dressing change.
	
CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: _________
Neck Vein Distention:   Y   N      Edema  Y    N
Location of Edema____________________	 
Tachycardia, can hear sounds of S1 and S2
Capillary refill 4 seconds
Edema around wound on LL	
RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character	
Breathing on own. Respirations short and close together

GASTROINTESTINAL:
Diet at home :                 Current Diet:   

Auscultation: Bowel sounds, other sounds
Last BM, character &  freq of stools 
Palpation: Pain, Mass etc
Inspection: distention, incisions, scars, drains, wounds
Ostomy:    Y       N         Nasogastric:    Y      N  
Feeding tubes/PEG tube   Y      N      Type:___________	
On liquid restrictions and cardiac diet
Increased output after medications taken. Made two BM – both were light brown, large and solid. Intake/Output of urine relatively equal.
Incision on LL and R Radial.	
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: _________
Drains present:  Y         N       Type_______________		
EENT: 
Ears:                            Eyes:
Nose:                          Teeth:            

GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis   Y      N 
Inspection of genitals
Catheter:  Y    N      Type_____________	

	
PSYCHOSOCIAL/CULTURAL:
Educational level

Developmental level       

Coping methods          

Health Beliefs
Occupation (previous if retired)

Religion & what it means to pt.

Personal/Family Data    (Think about home environment, family structure, and available family support)	

USE THE BACK OF THE SHEET FOR ADDITIONAL SPACE FOR DETAILS. EXPECTATIONS MAY VARY FOR DIFFFERENT COURSES

Journal: Use additional pages as necessary							(5 pts)								
 Address the following questions as you reflect on your clinical experience.
1.	What was you planned schedule for the morning’s activities?
    (For example arrive 0630 to review medications & labs, 0700 get report, 0715 get vital signs & plan am care with patient)
2.	How accurate was your plan? Were there changes? If so Why were the changes necessary?
3.	What did you learn from your clinical experience today?  
4.	Did clinical practice today align with what was discussed in class and/or lab?    Elaborate.	                                                       
5.	If today could be repeated what would you do differently?
6.	Describe 2 ways you saw caring demonstrated today?
7.	Describe how you demonstrated or observed respect in the clinical setting.
8.	Do you have any concerns or questions related to clinical that you would like to reflect on or discuss?

				

Reference List for all references used in this document.    Use APA format.          			                 (1 pts)