Lakeview College of Nursing
Clinical Preparation Assignment
N210 
Student Name: Amanda Miller Date: 10/2/11 Adm. Diagnosis:Chronic Renal Failure Allergies:codeine, vancomycin, heparin(bovine), amiodarone, prednison
                                                                                                                                                                                                                                        (5 pts)

Patient Initials: D.H. Age: 59  Date of Admission: 9/28/11

Gender:   M     F    Ethnicity: Caucasion 

Occupation: Navy 1975-1985, Ford Factory, Agricultural Farm. No longer works because mentally disabled. 
(Former work if retired)

Education: Masters in Business

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

I live with his fiancé. 

Do I have any other family? Has a brother and 2 sons. 

Adm. Date: 9/28/11 Adm. History: (What brought me to hospital?)			
 D.H was admitted to hospital for a Pleural Effusion. 

I have had these procedures while I have been here: Chest X-ray

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: ________________________________________

Medical History: Mitral valve disorder(424.0CN). Heparin induced thrombocytopenia (289.85C). DVT (deep venous thrombosis) (453.40U). Nephritis (583.9). Back Pain (724.5E). Polyarthralgia (719.49B) HTN (Hypertension) (401.9AE). Depression (311G). Mitral valve insufficiency (424.0M). Nicotine Dependence (305.1A). Hemorrhoids (455).
Surgical History: Mitral valvul oplasty(SHX143)

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    
       ________/10     I describe it as. 
Steady low-grade, sharp stabbing pain. Patient wouldn’t put a number on pain scale. Said His pain was tolerable at time. 

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	NO W	TEST	NORMS	BEFORE	NOW	
WBC	4.00-11.00 103/ul	12.26	18.24	RBC	4.10-5.70 106/ul	3.03	3.53	K	3.6-5.0mmol/L	3.9	3.9	
DIFF: 
Monocytes

Lymphocytes

Neutrophils
Eosiniphils
Basophils	
4.4-12.3%
20.0-45.0%

0.3-5.2%
0.0-2.0%	
9.0

9.0

3.0
1.0	
10.0

1.0

13.0
1.0	HGB/ HCT	12.0-18.0g/dl
37.0-51.-%	8.4

26.6	9.9

30.9	NA	135-145 mmol/L	131	133	
PT				PLT	140-400 10 3/ul	158	205	CL	101-111mmol/L	100	101	
INR	0.9-1.1 ratio	1.3		APTT				CA		8.2	8.0	
GLUCOSE	60-99mg/dl	97	104	A1-C				CO2	21.0-31.0mmol/L	22.0	23.2	
CHOLESTROL	101-200mg/dl	220	220	BUN	6-20mg/dl	16	20	MG				
TRIGLYCERIDE	50-193	109		CREATININE	0.50-1.20mg/dl	1.93	2.17	TSH				
HDL/LDL
		137		BNP				phosphorus	2.5-4.6	3.6	4.4
	
ALB 	 3.2-5.5gm/dl	2.0		TBIL	0.2-1.0mg/dl	0.5		TP	6.0-8.1gm/dl	6.4
		
AST	12-50IU/L	16		ALT	10-75IU/L	12		ALKP	42-121IU/L			
Fe	50-160mcg/dl	19		Transferrin	180.0-329.0mg/dL	91.9		T.iron binding cap	250-400 mcg/dl	137
		
%saturation	15-50%	14		CK TOTAL	22-269U/L	129		CK-MB	0.0-4.0ng/ml	2.8		
Ferritin	24-336ng/ml	1970		GFR:NAA		36	31	GFR;AA		43	38	
MCV	80.0-100.0fl	87.8	87.5	MCH	27.0-33.0pg	27.7	28.0	MCHC	32.0-36.0g/dl	31.6	32.0	
RDW	12.0-15.0%	15.9	16.1	RDW-SD 	36.7-46.1fl	50.4	51.0	MPV	9.0—12.0fl	9.7	9.6	
SEG	32.5-74.8%	68.0		BAND	0.0-6.0%	6.0		Metamyelocte		2.0		
Myelocyte		2.0										
DIAGNOSTICS:  Test & Results                                                                                                                                                                     
   Chest X-Ray: Chest AP or PA ONLY-the right chest tube remains. Heart size stable. Mild vascular congestion is moderately improved. There is persistant demonstration of small right costophrenic sulcus hydropneumothorax atelectasis versus infiltrate at the right lung base.                                                                                                                      
     
     EKG:  Complete 2d echo with spectral/color Doppler- mid ascending aorta measures 5.5cm and is aneurismal. Overall left ventricular systolic function appears normal based on limited images. Mild Tricuspid regurgitation. S/p mitral annuloplasty

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)Chronic Renal Failure2. Describe the pathology of this disease; include any causative factors/etiologies that can be identified.     (5 pts)
Patient has stage 3 chronic renal failure, most likely secondary to non resolving interstitial nephritis from previous episode. Showing reduction of his creatinine from 2.22-1.8 and increase of his estimated GFR 30-37 with no uremic or volume overload manifestations and no major acid-base or electrolyte abnormalities with nonoliguric urine output.
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 p
4. Relate the medications to the disease process or patient situation; include any precautions to be aware of when administering.        (3 pt
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).	
Albuterol-ipratropium (Combivent) 18-103mcg/actuation inhaler 2 puff
Admin amount: 2 puff
Route:Inhalation
Freq:4 times daily
Admin instruction: Use spacer with inhaler each time. 
“Return to Pharmacy for disposal”
Order Start Time: 9/29/11 1800
Last Admin Given: 10/01/11 2109

Alteplase (Activase) 20 mg in 0.9% NaCl 100 ml
Admin Amount: 20mg
Route: intrapleural
Freq: Daily
Admin Instructions: Please place in foley tip catheter syringe
Order Start Time: 10/1/11 0900
Order End Time: 10/03/11 0859
Last Admin Given: 10/01/1059

Amlodipine (norvasc) tablet 10 mg
Admin amount: 1 tablet (1x10mg tablet)
Route: Oral
Order Start Time: 9/29/11 1340
Last Admin given: 10/02/11 0627

Ascorbic acid (vitamin C) tablet 500 mg
Admin amount: 1 tablet (1x500mg tablet)
Route: Oral
Freq: Daily
Order start time:09/29/11 1340
Last Admin given: 09/30/11 0814

Docusate Sodium (Colace) Capsule 100 mg
Admin amount: 1 capsule (1x100mg capsule)
Route: Oral
Freq: daily
Admin instructions: hold for loose stools
Order Start Time: 09/29/11 1340
Last Admin Given: 09/30/11 0814

Famotidine (pepcid) tablet 10 mg
Admin amount: 0.5x 20mg tablet)
Route: Oral
Freq: 2 times daily
Order start time: 9/29/11 1800
Last Admin Given: 10/01/11

Ferrous sulfate tablet 324 mg
Admin amount: 1 tablet (1x324mg tablet)
Route: oral
Freq: 2 times daily
Admin instructions: do not crush this dosage form
Order start time: 10/1/11 1117
Last Admin Given: 10/1/11 1801

Fluconazole (Diflucan) tablet 200 mg
Admin amount: 1 tablet (1x200 mg tablet)
Route: oral
Freq: daily
Order start time: 9/29/11 1430
Last admin given:9/30/11 0816

Lisinopril tablet 5 mg
Admin amount: 1 tablet (1x5mg tablet) 
Route: Oral
Freq: 2 times daily
Order Start time 10/01/11 1125
Last admin Given: 10/01/11 1801

Loratadine (Claritin) Tablet 10 mg
Admin amount: 1 tablet (1x10mg tablet)
Route: oral
Freq: Daily
Order Start time: 9/29/11 1340
Last admin given: 9/30/11 0813

Meropenem (merrem) 500 mg in D5W 100 mL IVPB
Admin amount:500 mg
Route: IVPB
Freq: Every 8 Hours
Order infusion rate :100 mL/hr
Duration: 1 Hours
Admin instructions: activate vial before infusing
Order start time: 9/30/11 1820
Last admin given: 10/02/11 0627

Metoprolol (lopressor) tablet 100mg
Admin Amount: 1 tablet (1x100 mg tablet)
Route:Oral
Freq: Every 12 hours
Order Start Time: 9/2911 1340
Last Admin Given: 10/01/11 0923

Metoprolol tablet 12.5 mg
Admin amount: 0.5tablet (0.5x25mg tablet)
Route: Oral
Freq: Q12H/0700 &1900
Order Start time: 9/30/11 1900
Last Admin given: 10/02/11 0627

Sennosides (senokot) tablet 17.2 mg
Admin Amount: 2 tablet (2x8.6mg tablet)
Route: Oral 
Freq: 2 times daily
Order Start time:9/29/11 1800
Last Admin Given: 10/02/11 0922

Thaiamine (Vitamin B-1) tablet 100 mg
Admin amount:1 tablet  (1x100 mg tablet)
Route: Oral
Freq: Daily
Order Start Time: 9/29/11
1340
Last Admin Given: 10/02/11 0922

Torsemide (Demadex) tablet 20 mg
Admin Amount: 1 tablet (1x20mg tablet)
Route: Oral 
Freq: Daily (loop diuretic)
Order Start Time: 10/01/11 1125
Last Admin given: 10/02/11 0922

Zolpidem (Ambien) tablet 5mg
Admin Amount: 1 talbet (1x5mg tablet)
Route: Oral
Freq: at bed time
Order start time: 9/29/11 2100
Last admin given: 10/1/11 2109

PRN
Albuterol-ipratropium (Duoneb) 2.5-0.5mg/3ml nebulizer solution 3mL
Admin amount: 3mL
Route: Nebulization
Freq: Rt Every 4 hours PRN
Order Start Time: 9/29/11 1338
Last Admin Given: 10/01/11 1618

Hydralazine (apresoline) injection 10mg
Admin Amount: 0.5 mL = 10mg of 20mg/ml
Route: IV push
Freq: Every 4 hours PRN
PRN Reason: Other-list in PRN Comment: SBP>120
Admin instruction: IV Push should be given over 1 minute
Order Start Time: 10/01/11 1049
Last Admin given: 10/01/11 1841

Hydralazine (apresoline) injection 20 mg
Admin amount: 1ml=20 mg of 20mg/ml
Route: IV push
Freq: every 4 hours PRN
PRN comment : SBP>130
Admin instructions: IV push should be given over 1 minutes
Order start time: 10/01/11 1015
Last admin given: 10/01/11 2313

Hydrocodone-acetaminophen (NORCO) 5-325 mg tablet 1 tablet
Admin amount: 1 tablet
Route: Oral
Freq: Every 4 hours PRN
Admin instructions: do not exceed 4 g acetaminophen (tylenol) per 24 hours
Order Start time: 9/29/11 1338
Last admin given: 10/02/11 0921

Sodium Chloride 0.65%(Ocean Nasal) nasal spray 2 spray
Admin amount: 2 spray
Route: Each Nostril
Freq: as needed
10/01/11 1007
Last Admin Given: 10/01/11 1616

IV
Meropenem (merrem) 500 mg in D5W 100 mL IVPB
Admin amount:500 mg
Route: IVPB
Freq: Every 8 Hours
Order infusion rate :100 mL/hr
Duration: 1 Hours
Admin instructions: activate vial before infusing
Order start time: 9/30/11 1820
Last admin given: 10/02/11 0620

	Drug Class: Beta-Adrenergic and Anticholinergic Combinations
Actions:  reduces bronchospasm through both anticholinergic and sympathomimetic mechanisms. Simultaneous administration of both drugs produces a greater bronchodilator effect than when either drug is used alone at recommended doses. 

Drug Class: Thrombolytic Enzymes
Action:

Drug Class: Calcium Channel Blocking agents.
Actions: long-acting dihydropyridine calcium channel blocker that exerts its effects by blocking the transmembrane influx of calcium ions into cardiac and vascular smooth muscles. Reduces peripheral vascular resistance and lowers blood pressure by causing a direct vasodilation in peripheral arteries of the vascular smooth muscle. Therapeutic effect on angina may be through a decrease in peripheral resistance and inhibition of coronary spasm

Drug Class: vitamin C preparations
Actions: essential for collagen formulation and tissue repair

Drug class: laxatives and Cathartics
Actions: stool softener used for temporary relief of constipation. It works by actively drawing water into the stool, thus softening the stool and achieving ease in bowel movement. 

Drug Class: histamine H2-receptor inhibitors
Actions:inhibits both the concentration and volume of gastric secretion. Does not affect gastric emptying or exocrine pancreatic function, more so, it has little or no effect on fasting or postprandial serum gastrin levels. 

Drug class: iron replacement. 

Drug class: Antifungal Agents
Action: inhibits fungal sterol synthesis leading to aggregation of 14 alpha-methyl sterols in the fungi, which is responsible for the fungistatic activity

Drug class: antihypertensives, ace inhibitors
Action:Ace inhibition prevents the conversion of angiotensin I to angiotensin II which is potent vasocontrictor. Decreased angiotensin II leads to decreased vasosupressor activity and decreased aldosterone secretion. 

Drug class: antihistamine-2nd generation.
Action: selectively blocks peripheral histamine H(1)-receptor activity

Drug Class: Carbaenems (Thienamycins)
Action: 

Drug Class: Beta-Adrenergic blocking agents.
Actions: beta-adrenergic blocker with selective activity on beta (1) adrenoreceptors located mainly in cardiad muscles. At higher doses, it may inhibit beta (2) adrenoreceptors of bronchial and vascular smooth muscles

Drug Class: Beta-Adergenic
Actions: beta-adrenergic blocker with selective activity on beta (1) adrenoreceptors located mainly in cardiad muscles. At higher doses, it may inhibit beta (2) adrenoreceptors of bronchial and vascular smooth muscles

Drug Class: Laxatives and Cathartics 
Actions:

Drug class: Vitamin B1 Preparations
Action: combines with adenosine triphosphate(ATP) to form coenzyme, thiamine pyophosphate, which is necessary for carbohydrate metabolism.

Drug Class: Loop Diuretic
Action: inhibits reabsorption of sodium and chloride in the luminal membrane of the ascending limp of the loop of Henle by interfereing with the chloride binding site of the 1Na+, 1K+, 2Cl- contransport system. 

Drug Class Sedative-hypnotics, Non-barbiturate.
Action:the preferential binding of zlpidem to the BZ1 receptor may explain the relative absenes of myorelaxant and anticonvulsant effects as well as the preservation of deep sleep (stages 3 and 4) of zolpidem at hypnotic doses

Drug class: Beta-Adrenergic and anticholinergic
Action: reduces bronchospasm through both anticholinergic and sympathomimetic mechanisms. Simultaneous administration of both drugs produces a greater bronchodilator effect than when either drug is used alone at recommended doses.

Drug Class: Antihypertensives Vasodilators
Actions: unknown mechanism of action, dcecreases blood pressure by exhibiting a peripheral-vasodilating effect through a direct relaxation of vascular smooth muscle. 

Drug Class: Antihypertensives Vasodilators
Actions: unknown mechanism of action, dcecreases blood pressure by exhibiting a peripheral-vasodilating effect through a direct relaxation of vascular smooth muscle.

Drug Class: Analgesic, narcotics
Acetaminophen: 1.3 g/4g within last 24 hours as of sun Oct 2, 2011 0949
Action: non opiate, non-salicylate and antipyretic. Inhibits prostaglandin syntheses. 

Drug Class: Nose preparations, miscellaneous (OTC)
Action: source of water and electrolyte. 

Drug Class: Carbapenems (Thienamycins)	Dilate the bronchials. 

Control blood pressure.

Help repair skin. 

Relieve constipation. 

Relieve heart-burn.

Reverse anemia. 

Antifungal. 

Lower Blood pressure.

Allergy relief

Lower Blood Pressure. 

Lower blood pressure.

Help with BM. And Relaxation. 

Digestion.

Frequent Urination. 

Sleep aid. 

 	Hypersensitivity to soybean, peanut products. 
Bladder neck obstruction; anticholinergic effects of ipratropium bromide may worsen condition. 
CV disorders, especially coronary insufficiency, cardiac arrhythias, and hyptertension: clinically significant CV effects may occur. 
Concomitant use of MAO inhibitors or tricyclic antidepressants, or therapy within 2 weeks; consider alternative therapy. 

Aortic stenosis, severe; symptomatic hypotension may occur
Hepatic impairment, severe; slowly titrate dose
Obstructive coronary artery disease, severe; increased risk of worsening angina or acute myocardial infraction after initiating or increasing dose.

Concurrent anticoagulant therapy
Concurrent sodium-restricted diet
Diabetes
Recurrent renal calculi
Patients undergoing stool occult blood tests
Doses 500mg/day or more may interfere with urinary glucose tests. 

Sudden change in bowl habits of over 2 weeks duration.
Use for longer than 1 week.
Rectal bleeding or the failure to have a bowel movement after use of a laxative.

Renal insufficiency, moderate or severe; risk of prolonged QT interval and CNS adverse effects; dose adjustment recommended. 

Anaphylaxis has been reported rarely
Concomitant use of voriconazole is not recommended
Concomitant use of erythromycin is not recommended
Exfoliative skin disorder have been reported rately. 

Aortic stenosis. 
Apheresis, low density lipoprotein with dextran sulfate absorption; anaphlactoid reactions have been reported 
Cerebrovascular disease; risk of drug induced argranulocytosis
Congestive heart failure, severe; possible risk of oliguria, progressive azotemia and or acute renal failure. 

Impaired liver and renal function. 

May exacerbate angina pectoris or cause myocardial infraction
May precipitate a thyroid storm
Anesthesia and maor surgery; impairs ability of heart to respond to reflex adrenergic stimuli; however chronic beta blocker therapy  should NOT routinely be withdrawn. 
Hepatic impartment

May exacerbate angina pectoris or cause myocardial infraction
May precipitate a thyroid storm
Anesthesia and maor surgery; impairs ability of heart to respond to reflex adrenergic stimuli; however chronic beta blocker therapy  should NOT routinely be withdrawn. 
Hepatic impairment. 

Requirements may be increased in the following conditions; alcoholism, burns, fever, gastrectomy, hemodialysis, hepatic-biliary tract disease, infection, intestinal disease, manual labor, heavy, for long periods of time. 

Cardiovascular disease, especially those patients receiving glycosides; diuretic-induced hypokalemia may increase risk for development of arrhythmias
Liver disease with cirrhosis and ascites; sudden alterations of fluid and electrolyte balance may precipitate hepatic coma. 
Abrupt withdrawl or rapid dose decrease; may cause severe withdrawl symptoms. 
Anaphylaxis; may occur as early as the first dose or subsequent doses. 
Angioedema, possible; may occur  as early as the first dose or subsequent doses. 

Hypersensitivity to soybean, peanut products. 
Bladder neck obstruction; anticholinergic effects of ipratropium bromide may worsen condition. 
CV disorders, especially coronary insufficiency, cardiac arrhythias, and hyptertension: clinically significant CV effects may occur. 
Concomitant use of MAO inhibitors or tricyclic antidepressants, or therapy within 2 weeks; consider alternative therapy. 

History of cerebrovascular disease or stroke
Coronary artery disease
Liver disease
Mitral valve disease
Renal impairment 
Systemic lupus erythematosus.

history of cerebrovascular disease or stroke
Coronary artery disease
Liver disease
Mitral valve disease
Renal impairment 
Systemic lupus erythematosus.

Severe liver injury, including acute liver failure resulting in transplant and death, has been reported with acetaminophen use.
Addisons disease 
Respiratory depression
Renal impairment. 

Cardiac insufficiency, increased risk of sodium retention, requires regular monitoring of fluid status in patients receiving 3% to 5% sodium chloride injection
Edema with sodium retention, preexisting;potential worsening of clinical condition

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.	
D.H. will ambulate with assistance from bed to window at end of hall by 12:00.

	Nurse will 			
	                             (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 %:
94	BP:
112/56	Pulse:
Rate:98
Rhythm: regular	Respirations:
Rate:10
Rhythm: even-non-labored	Temp:
99 F

Route:Oral	Pain:
Rating:      N/A   /10    Characteristics:          	Ht:1.803m (5’11’’)
Wt: 86.682kg (191)	
NEUROLOGICAL: 
 MAE:   Y        N           PERLA:    Y         N
Strength Equal:   Y      N   if no -   Legs   Arms    Both 
Orientation, Mental Status, Speech, Sensory, LOC, 	Awake and oriented. Audible speech pattern. 

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	Is on fall precautions. Needs assistance moving from bed to commode. Has the desire to walk with a walker. Requested a walker to go to the bathroom with, however opted to use the bedside commode instead. 	
CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: <3 seconds
Neck Vein Distention:   Y   N      Edema  Y    N
Location of Edema: Ankles	 I heard both S1 and S2 sounds going from the aortic location to the apical pulse. 	
RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character	Left upper chest was clear. Right lower back had crackling from the suctioning. 
	
GASTROINTESTINAL:
Diet at home :   regular              Current Diet:  regular 

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:___________	At 1030, patient had large, soft-formed stool that was brown in color. 
Prior to this stool, patient says he hadn’t had a BM since Saturday. 
Auscultation of bowel sounds unavailable 
Found 4 stage II pressure ulcers on coccyx when performed perineal care. 	
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: _________
Drains present:  Y         N       Type_______________	Skin was reddish pink in color. Dry rough skin with flakes. Hair was regular on arms and legs. Hair was balding. Edema was on ankles. Scar from sternum to below the costal margin from previous surgery. 
	
EENT: 
Ears:Wore hearing aids                  Eyes: Wears glasses
Nose: no drainage                         Teeth: no dentures           
                             	Patient has auditory difficiency. Had trouble hearing.
	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis   Y      N 
Inspection of genitals
Catheter:  Y     N      Type_____________	Had a 200 cc output of urine. Urine was yellow in color and clear. .Had 2 previous series of dialysis. Last dialysis series was on the September 19th 2011. Genitals were normal without 

	
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)