Lakeview College of Nursing
Clinical Preparation Guide and Process Paper
50 Points Total

Student Name Christine Wenthe Date 9/27/2012  Client Initials ER Allergies Sulfa drugs, Sulfatones (1pt)  Primary Diagnosis (1pt)

Current Medical Issues: (4pts)

•	History of Physical Illness (HPI):
o	Initials ER  Age80  Date of Admission 9/27/2012

o	Tell the story of how your patient ended up in the hospital (this is the chief complaint)l:
Presented in the ED with generalized weakness having shakes, no emesis. Pt has hypotension and is receiving intrabladder treatment for bladder cancer. 

•	Medical History: (list year of diagnosis)									 Surgical history (list year of surgery):
Coronary artery disease, HTN, Gout,									PTCA/stenting coronary arteries 2004. Hemicolectomy per large 
Adenomatous colon polyp appendectomy, cholecystectomy bilateral 	
Cataract extractions & bladder tumor resection
 Hyperkalemia, Hyperlipidemia, Hypoglycemia, Renal failure	

•	Social history – 
o	Occupation: Retired

o	Lives with: Married										Any other Family members:

o	Habits: Tobacco, Alcohol, Drugs: Pack for 20yrs, quit 40 yrs ago. No alcohol or illicit drug use.

Nursing Note (review 2-4 nurses’ notes and record notes):  (1pt)
9/26/12- Blood cultures drawn. SP02 dropped to 85% while sleeping 3 lpm via NC
Pt went into ST

Nursing Care (4 pts)
Pain – level____/10   source______________		Isolation: isolation precaution               
Fall risk – yes     
Hygiene –  total        partial           independent
Activity – up ad lib         needs assistance:  yes     -#  to assist__________
Diet – Reg     
IV or Heplock -    yes             type of IV fluid Normal Saline
Foley catheter -    yes    
Code status – DNR

 Laboratory Testing: (6 pts)
•	Hematology:	    Value	 Is value normal? 	If not, why? Please relate to disease process if possible.
o	WBC  3.6	  Yes	x No	nomal range 4.5-10.000 infection

o	RBC	 3.48	 Yes	 No	_______________________________________________

o	HCT	 31.6	 Yes	x No	normal range 36.1-44.3

o	Hgb	 10.6	 Yes	x No	 Range 12.1-15.1

o	PLT	 57	 Yes	x No	normal range 150-400 infection

•	
•	Chemistry:	   Value:  Is value normal?      If not, why? Please relate to disease process
o	Na	143	x Yes	 No    ___________________________________	
o	K	3.5	xYes	 No    ___________________________________

o	Cl	104	x Yes	 No    ___________________________________	
o	BUN	  39	 Yes	x No	normal range male 8-24

o	Cr	1.21	x Yes	 No	___________________________________

o	Gluc  174	 Yes    x No      Pt may have just eaten. Range 70-100

Other Labs: __________________________________________________		

Diagnostic Imaging:  
a.	In your own words, why is this test done – relate this to the pathology.  
b.	If abnormal, what changes in your nursing care need to be made?
•	Chest X-ray
-hospital acquired pneumonia.

•	Ultra Sound

Scan the bladder and kidneys. Acute renal failure.

PATHOPHYSIOLOGY:  3 parts, answer all 3 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, relate to patient symptoms.     (3 pts)

3. Relate the abnormal and/or significant labs and diagnostics to the disease process.  If all tests are WNL then indicate which values are important to monitor and explain why. Be specific. Include probable complications and outcomes for this patient.      (3 pts)

Reference List for all references used in the entire document.    Use APA format.          			           (2 pts)	

Taylor, L., & LeMone, L. (2011). Fundamentals of nursing: The art and science of nursing care. (7th ed.). Philadelphia,PA: Wolters Health/ Lippincott Williams & Wilkins.
Skidmore-Roth, L. (2012). Mosb'ys 2013 nursing drug reference. (26 ed.). St. Louis, MO: Elsevier.

Medication Summary Sheet (Be ready to relate your medications to your disease process)
List all medications your patient has used in the last 24 hours including: 
1.	Medication name (generic) with prescribed dose & frequency, 
2.	The usual dose & frequency, 
3.	Classification & mechanism of action, 
4.	Why this medication is being used for this patient, 
5.	What nursing precautions considerations do you need to know to SAFELY administer / monitor this medications and lastly 
6.	Evaluate the medications effectiveness for this patient (patient response).  (0 pts)
Name (generic) 
prescribed dose 
& frequency, 
usual dose & frequency	Classification/
Mechanism 
of action	Why use this 
medication 
for this 
patient?	Nursing precautions/ 
safety considerations
To administer this medication	Evaluation
Patient response	
Ondansteron HCI
4mg 

	Antiemetic	Prevents nausea and vomiting 	Hypersensitivity reaction: rash brochospasim.
Evaluate therapeutic response: absence of nausea, vomiting 		

Acetominophen (Tylenol)
650 mg					
Insulin Human Regular
sliding scale
					
Calcium Carbonate
500mg
					
Albuterol/Ipratropin
3ml
					
Acetominophen
(ofrirmal) 100mg
					
Al Hydrox/mg
Hydrox/Simethicone
30 ml
					
Pantaprazole Sodium
40 mg
					
Lactulose
20g					
Multivitamins
1 ea Daily
	Vitamins	Prevention and treatment of vitamin deficiencies	Assess:
Hypersensitivity, anaphylaxisis: dyspnea, bronchospasm, urticaria, tachycardia		
Diltazem/ Sodium Chloride
100ml @ 5mls/hr

Nystantin
5ml
					
Vancomycin HCI
1250mg/ Sodium Chloride
250ml @ 250mls/hr
					
Piperacillin Sod/ Tazobactam Sod. 
2.25g/ Sodium Chloride
100ml @200 mls/hr					
Fat emulsion
250ml @ 20.833 mls/hr					

PHYSICAL ASSESSMENT DATA (collect own data on clinical day)     (Use Taylor Chapter 25 & N201 materials as resources)  (0 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 %:	BP:	Pulse:
Rate:
Rhythm:	Respirations:
Rate:
Rhythm:	Temp:

Route:	Pain:
Rating:         /10    Characteristics:          	Ht: _________
Wt: _________	
NEUROLOGICAL: 
 MAE:   Y        N           PERLA:    Y         N
Strength Equal:   Y      N   if no -   Legs   Arms    Both 
Orientation, Mental Status, Speech, Sensory, LOC, 	

	
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	

CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: _________
Neck Vein Distention:   Y   N      Edema  Y    N
Location of Edema____________________	 
	
RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character	

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:___________		
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)	

(5 pts)  Interventions

Assess vital signs 	

(5pts)  Data Supporting Problem

                                                                                                                               Nursing Concept Map                                                                                                                          
(2pt)          Problem(s)

Acute Renal Failure

Hospital acquired pneumonia

ST Goal: (2pts) 

LT Goal: (2pts) 

(5 pts) Evaluation of Plan

(Nursing Diagnosis: (3pts)