Lakeview College of Nursing
Clinical Preparation Assignment

Name: Jerome Jimenez Date/Week: 1/28/13 Adm. Diagnosis: Acute Pancreatitis Allergies:ampicillin, seroquel, penicillin G, escitalopram
                                                                                                                                                                                                                              10  (pts)

Initials:JG Age: 42    Ht. 6’0”  Wt. 123lb

Gender:   M     F        Ethnicity: Causcasion

Occupation: Construction worker

Education: NA

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

I live with: Wife

Do I have any other family? Wife (Alice)

Admission Info: (why and how did I come to hospital)
Patient was feeling acute pain in abdominal area. (Acute alcohol pancreatitis)

I have had these procedures while I have been here:
Sequential compression stockings
CT Scan (brain)

I need help with:   Hygiene      Moving        Eating       Dressing

I need help:         Not at All        Some           Lots             Totally

I have a     DNR      POA      Living Will

Activity Level: ________________________________________

Medical History: ETOH Abuse (9/1/11), Anxiety state, unspecific (09/1/11), Panic attack (09/1/11), Tobacco use disorder (09/1/11)

Surgical History: NA

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    
       9/10 I describe it as
Patient experience throbbing abdominal pain

  
  LAB DATA    (List all pertinent/current lab/diagnostic values)                                                                                                                  5 (  pts)
TEST	NORMS	ON ADM	NOW	TEST	NORMS 	ON ADM	NO W	TEST	NORMS	ON 
ADM	NOW	
WBC	4.00-11.00	10.7	6.72	RBC	4.10-5.70	2.36L	2.93L	K	3.5-5.1 mmol/L	1.7L	4.4	
DIFF: 
Monocytes
Lymphocytes
Neutrophils
Eosiniphils
Basophils	
4.4-12.3
20.0-45.0
1.60-7.70
0.0-0.50
0.0-0.20	
10.0
8
8.2 H
0L
0	
10.7
26.5
4.14
0.05
0.03	HGB/ HCT	12.0g/dL/37.0-51.0	10.3/25.7L	8.7L/25.7L	NA	136-145 mmol/L	131L	139	
PT	N/A	N/A	N/A	PLT	140-400	173	228	CL	98-107 mmol/L	87L	107	
INR	N/A	N/A	N/A	APTT	N/A	N/A	N/A	CA	8.5-10.1 mg/dL	10.6H	8.8	
GLUCOSE	60-99 mg/dL	118H	119H	A1-C	N/A	N/A	N/A	CO2	21.0-32.0 mmol/L	21.0L	20.0L	
CHOLESTROL	N/A	N/A	N/A	BUN	7-18 mg/dL	3L	8	MG	N/A	N/A	N/A	
TRIGLYCERIDE	N/A	N/A	N/A	CREATININE	0.60-1.30 mg/dL	0.7	0.25L	TSH	N/A	N/A	N/A	
HDL/LDL
	N/A	N/A	N/A	BNP	N/A	N/A	N/A	OTHER	N/A	N/A	N/A	
DIAGNOSTICS:  Test & Results                                                                                                                                                       2PTS               
   Chest X-Ray:                                                    Other: CT Scan Parenchymal volume loss from alcohol abuse                                                                        
     
     EKG:                                                                Other:                                                                         Other:
	
CORRELATION: How does each abnormal test or lab relate to the diagnosis:                                                                              3PTS            

	

Pathophysiology:  Review all data collected and describe what is happening at the cellular, organ, & system level, may use admitting or secondary diagnosis depending on Instructor preference.		                                                       5 (pts)		

 MEDICATIONS:                                                                                                                                                                    10  (pts)                     

List all medications you give on your shift..

Name, dose & frequency of administration for this patient. Plus usual dose and frequency of prescription.	Classification & mechanism of action. [Use your drug guide!]	Why is medication ordered for THIS patient?	 Nursing Precautions/ Considerations with this medication. 	 Evaluate medication effectiveness for THIS patient (patient response).	
Nictone patch (Nicoderm CQ) Daily transdermal

	Cholinergic. Smoking cessation agent. Nicotine acts as an agonist at the nicotine receptors in the autonomic ganglia, adrenal medulla, neuromuscular junction, and brain	For smoking cessation	Can cause hypertension, MI, peptic ulcers. Assess patient for MI symptoms and high blood pressu.re	Pt expresses that he no longer has an urge to smoke.	

PHYSICAL ASSESSMENT DATA      (COLLECT OWN DATA)                                                                                             10 (pts)
Vital Signs:
Pulse Ox %:
99% Room air	BP:
128/92
L Brachial	Pulse:
106
Rhythm:
Regular	Respirations:
Rate: 20
Depth: Shallow then deep
Rhythm: irregular	Temp:
97.4
Route:
Oral	Pain:
Rating:        9 /10    
Characteristics: Throbbing abdominal pain         	
NEUROLOGICAL: 
 MAE:   Y        N           PERLA:    Y         N
Strength Equal:   Y      N   if no -   Legs   Arms    Both 
Orientation, Mental Status, Speech, Sensory, LOC, 	Alert and oriented x3. Groggy. Sleepy. Patient has a tendency to be alert then goes back to sleep.

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	High fall risk. Max lift risk 3+ caregivers. Strength is equal bilaterally upper and lower. Pt needs lots of help. Appeared to be very weak and groggy from meds. Pt uses bedside commode.

CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: _________
Neck Vein Distention:   Y   N      Edema  Y    N
Location of Edema____________________	 No edema. S1 and S2 present. No S3 or S4 heard. No murmurs. Palpitations near left clavicle at neck. 
	
RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character	Shallow breathing followed by intermittent big huffs. Equal bilateral and clear.
	
GASTROINTESTINAL:
Diet at home :  reg               Current Diet:   TPN

Height: 6’0”                       Weight: 123lb

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:___________	No foley present. Bowel sounds are not active. Last BM was this morning (watery, no pain). PT was experience abdominal pain; therefore, I was unable to palpate for masses.	
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: _________
Drains present:  Y         N       Type_______________	Matches ethnic back ground. Excessive dryness on arms. No bruising or tenting. Buttocks slightly red.	
EENT: 
Ears:                            Eyes:
Nose:                          Teeth:                                       	Little bit of bleeding on tongue and lips. No occlusions are drainage from EENT. PT noted that his mouth was feeling dry.
	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis   Y      N 
Inspection of genitals
Catheter:  Y    N      Type_____________
	Urinated this morning. Output of 300mL. Urine was dark yellow.

	
PSYCHOSOCIAL/CULTURAL:
Religion & what it means to pt.

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

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

List ANY DATA/ FINDINGS i.e. Signs & Symptoms, Family Info, History etc. that have or could have any impact on the care for this client/patient.					             15  (pts)

PROBLEM						NURSING DIAGNOSIS						PRIORITY LIST 5PTS
PT is prone to falling

PT has difficulty with coping with being in hospital

PTis bed ridden

PT is TPN	Pt at risk for injury

Ineffective coping

Risk for skin integrity impairment

PT as rick for insufficient nutrient intake	PT at risk for falling

PT at risk for integrity impairment	

1st Priority Nursing Diagnosis:  (2  pts)
																
Nursing Diagnoses PT is at risk for injury R/T falling 

AEB assessment and classification of being a fall risk.

2nd priority Nursing Diagnosis: (2PTS)
	
Nursing Diagnosis Patient at risk for skin integrity impairment R/T limited activity

AEB Redness on lower back

Nursing Diagnosis (restated): 1PT
PT at risk for injury related to falling as evidence by assessment and classification of being a fall ris.

What does the patient/client need to accomplish?
GOALS/OUTCOMES
Nurse or client perspective
2PTS EACH	What can the nurse do to help resolve the problem?
IMPLEMENTATION
Nursing Interventions  
2PTS EACH	Why will the nurse do these actions?

SCIENTIFIC RATIONALE
Be sure to include source using APA format
2PTS EACH	How did the patient/family respond to the nurse’s actions? 
EVALUATION
Client Response, Status of Goals & Outcomes, Modifications to Plan
2PTS EACH	

1 PT/family will verbalize understanding of trauma/injury risk and its impact on the health status and functional performance by end of shift.

_____________________________

2 PT will verbalize importance of staying in bed by end of shift/	
Educate patient and family.

Educate patient and family.			
	                     pts                                                    pts                                                                 pts                                                             pts
Reference(s): List all on back page or attach additional page. Use APA format.2PTS)
MINI COG TEST: 1PT.

STUDENT WILL ASK THE PATIENT TO REMEMBER 3 WORDS AND REPEAT THEM LATER.
THEN STUDENT WILL ASK THE PATIENT TO DRAW A CLOCK WITH THE TIME OF 11:10 REPRESENTED ON THE CLOCK.  AFTER THE DRAWING OF THE CLOCK ASK THE PATIENT TO REPEAT THE WORDS YOU SAID BACK TO YOU. 

LIST YOUR FINDINGS:
ABLE TO REPEAT ALL THREE WORDS BACK:   

ABLE TO REPEAT 2 OF THREE WORDS BACK:  

ABLE TO REPEAT 1 OF THREE WORDS BACK:

NOT ABLE TO REPEAT ANY OF THE WORDS BACK:   

ABLE TO DRAW CORRECT TIME ON CLOCK:  YES OR NO

SPIRITUALITY TEST  1PT

DO YOU CONSIDER YOURSELF SPIRITUAL OR RELIGIOUS?   					YES OR NO
DO YOU HAVE SPIRITUAL BELIEFS THAT HELP YOU COPE WITH STRESS?			YES OR NO		

DOES YOUR FAITH OR BELIEF HAVE IMPORTANCE IN YOUR LIFE?				YES OR NO
HAVE YOUR BELIEFS INFLUENCED HOW YOU TAKE CARE OF YOURSELF?			YES OR NO	

ARE YOU PART OF A SPIRITUAL OR RELIGIOUS COMMUNITY?					YES OR NO
IS THIS OF SUPPORT TO YOU AND HOW?								YES OR NO
IS THERE A GROUP OF PEOPLE YOU REALLY LOVE OR WHO ARE
IMPORTANT TO YOU?											YES OR NO