Catherine Owens

   

Date: ________ Student Name: _______________________ Clinical Site:____________________________________

Clinical Site Instructor:___________________________________ __________________________________________

Room #_405_________Client Initials: ____SR___ ____Client age: ____52 years_______  Gender: ___Male_______

Allergies: Diphenhydramine______________________________ Code Status: ___Full code______________ ________________

Diet/Nutrition: _________Regular___________________ Activity: _______________________________ Fall Risk: Yes / No Yes (High fall risk)

Use of (type/amount/frequency): Alcohol: ___________________ Tobacco (pack years): ________________________

Treatments: _______________________________ IV/Tubes/Ostomies: ______________________________________

Dressings/Wounds: (type & location) _Shoulder-healing, Back-Tegaderm and clear absorbent.__________________________________________________________________

Oxygen: (delivery method & amount) ____N/A___________________________ Dialysis: ______N/A_____________________

LAB RESULTS: (minimum of 2 labs) Why is this lab significant for this client’s condition? Write down ABNORMAL lab results and include what the NURSE needs to monitor for or do related to the abnormal lab result under the significance column. ONLY USE ABNORMAL LAB RESULTS QSEN: Informatics, Safety SLO: 3, 8

Date  Test Normal Value Client Value Significance 

7/24 Sodium____135-145_   132

7/25 Hemoglobin 14-18    9.4 __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

LABS

Look at the 2 labs you looked up for this week. For each of the labs look up what body system or system(s) it tells you about, what does an elevated level mean, and what does a low level mean. Also, are there any special considerations or client education regarding prepping the client for the test? (example: fasting for 6 hours, etc.) QSEN: Informatics, Safety SLO: 3, 8

Lab Test#1: __Sodium 135-145_______________Systems affects: ______________________________________________

Elevated level: _____________________________________________________________________________

Low level: _132___________________________________________________________________________

Lab Test #2: _Hemoglobin 14-18_________________Systems affects: ______________________________________________

Elevated level: _____________________________________________________________________________

Low level: 9.4_______________________________________________________________________________

Date: ____________ Client Initials: _SR_____ Student Name: ___________________________­­­­____________________ 

Medical Diagnosis(s): (found in paper chart)

Admitting/Primary: Motor Vehicle Accident

____________________________________   ______________________________________

Medical History (includes medical and surgical)

 

Acute post hemorrhagic anemia _____________________________________

Alcohol abuse ___________________________________  _____________

PTSD____________________________________ 

Adjustment disorder with other symptoms___________________________________ ____

Traumatic ischemia of muscle__________________________________ ______________________________________

__________________________________ ______________________________________

____________________________________ ______________________________________

____________________________________ ______________________________________

End of Shift Report or SBAR: QSEN: Informatics, Team-Work Collaboration SLO: 3 

  

DATE


TIME


 



 



 



 



 



 



 



 



 



 



 



Date: ____________ Client Initials: ______ Student Name: _______________________________________­­­­_________ 

PRN Medication List (found in paper chart) QSEN: Safety, Evidence Based Practice. SLO: 2, 4

  

Medication

(Include dose, time, route, & Frequency)


Classification


Indication for use

 

OxyCODONE   (Immediate release) 5mg tablet-10mg PO



 

Ibuprofen 400mg tablet PO q6h



 



 



 



 



 



 



 



 



 



 



 



 



 



 



 



 



 



 



   

Medication Data Sheet

Date: ____________ Client Initials: ______ Student Name: ___________________________­­­­________________________

(Scheduled medications to be given to your client during your clinical shift) QSEN: Safety, Evidence Based Practice. SLO: 2, 4

  

Drug Name, Dose, Route   & schedule


Drug Classification,   Expected action & indication for use


Side Effects/ Adverse   Reactions 

(List 3-5)


Medication/Food   Interactions

(List 3-5)


Nursing Administration   Considerations & Assessments

(List 3-5)


Client education &   Evaluation of Medication Effectiveness

(List 3-5)

 

Mirtazapine 7.5mg PO at HS






 

Nicotine 21mg/24hr Patch   Transdermal






 

Gabapentin 100mg capsule PO






 

Methocarbamol 500mg   tablet-1000mg PO






 

Enoxaparin 40mg/0.4ml   injection 40mg subcutaneous






 

Melatonin 3mg tablet PO at   HS






 






  

Date: ____________ Client Initials: ______ Student Name: _______________________________________­­­­_________ 

Patient________________________ Room:__________ Hallway:_____________

Nurse: ____________________________ NA: _________________________

  

Temp


Oral/Tympanic 

 

HR


Regular/ Irregular 

 

BP


Laying/Sitting/Standing Right/left

 

Resp.


 

O2 %


Room Air/ Oxygen _____L 

 

Pain


 


Location: Description:

 


Pain Intervention:

Edema:

Location:__________________ Degree:________________ pitting/non-pitting

Lung sounds:

Right_______________________  Left_________________________

Cough?_____________________ SOB?__________________________

Bowel Sounds_________________________________________

Date of Last BM______________ 

Trach:  

Times Suctioned: Type of Trach suction: In-Line / Sterile

Vent Settings:

RR TV HA LA PEEP Mode

LMV Sensitivity Insp Time FiO2 O2  L 

Keep O2 above %

Treatments Done? 

Foot care Done?

PATHOPHYSIOLOGY: For each diagnosis below, provide a 3-5 sentence explanation of the pathophysiology of the problem. (**we count sentences**) QSEN: Evidence Based Practice, Informatics, Client Centered Care. SLO: 1, 2, 4

1. Primary Diagnosis: Open displaced fracture of pelvis

(3-5 sentences)

Treatments: (3 minimum)

Potential complications: (3 minimum)

Potential Nursing Diagnosis (2 minimum)

Potential Nursing Interventions: (2 minimum)

2. Diagnosis: Alcohol dependence with withdrawal

(3-5 sentences)

Treatments: (3 minimum)

Potential complications: (3 minimum)

Potential Nursing Diagnosis (2 minimum)

Potential Nursing Interventions: (2 minimum)

3. Diagnosis: Closed fracture of multiple ribs of left side

(3-5 sentences)

Treatments: (3 minimum) 

Potential complications: (3 minimum)

Potential Nursing Diagnosis (2 minimum)

Potential Nursing Interventions: (2 minimum)

4. Diagnosis: Closed fracture of transverse process of lumber vertebra

(3-5 sentences)

Treatments: (3 minimum)

Potential complications: (3 minimum)

Potential Nursing Diagnosis (2 minimum)

Potential Nursing Interventions: (2 minimum)

5. Diagnosis: Acute blood loss anemia 

(3-5 sentences)

Treatments: (3 minimum)

Potential complications: (3 minimum)

Potential Nursing Diagnosis (2 minimum)

Potential Nursing Interventions: (2 minimum)

6. Diagnosis: Respiratory failure

(3-5 sentences)

Treatments: (3 minimum)

Potential complications: (3 minimum)

Potential Nursing Diagnosis (2 minimum)

Potential Nursing Interventions: (2 minimum)

7. Diagnosis: Acute pain due to trauma

(3-5 sentences)

Treatments: (3 minimum)

Potential complications: (3 minimum)

Potential Nursing Diagnosis (2 minimum)

Potential Nursing Interventions: (2 minimum)

8. Diagnosis: Transection of urethra

(3-5 sentences)

Treatments: (3 minimum)

Potential complications: (3 minimum)

Potential Nursing Diagnosis (2 minimum)

Potential Nursing Interventions: (2 minimum)

Student evaluation of clinical performance:

Please describe any procedures/skills you performed/ observed during the clinical experience. Also, include your assessment of how well the day went.

  

    • Posted: 9 days ago
    • Due: 
    • Budget: $15
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