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Clinical Prep Sheet

Student Name: Nurse Nancy SVN Unit: 3-East Date: 01/01/2012 Clinical Wk#_1 Patient Initials: JDS Age: 86 Allergies: NKDA_________________________________

Medical Diagnosis for Admission to the Hospital Pathophysiology /Etiology/Cause for Medical Diagnosis

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|Primary Diagnosis and additional diagnosis |Short patho about primary diagnosis if needed attached additional page |

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|Chest Pain | |

|Hypertension | |

|DM | |

|Findings to be reported to HCP |HCP Orders |

|Based on medical diagnosis and nursing diagnoses, what complications could |Place physician orders here that pertain to your patient |

|occur and what you would report to the primary nurse and /or HCP | |

|Worsening skin integrity |Wound Care Nurse Consult |

|Purulent drainage from wound |Foley Catheter |

|Elevated temperature |Physical Therapy consult |

|Abnormal lab values |Diet: |

|Abnormal VS |Treatments: |

|Increase pain/discomfort |Activity Level |

| |Restrictions: |

Collaborative Care:

|Lab Data |Xrays / Procedures (Results) |

|Test/Exams that relate to your patients diagnosis and the normal and results of|Chest Xray (CXR) – Bilateral lower lobe infiltrates |

|the exams. | |

|Glucose- 280 | |

|CBC (H/H; WBC;RBC) | |

|BUN – 26 | |

|Creatinine- 2.0 | |

|Electrolytes | |

|Urinalysis | |

Nursing Assessment Findings

|Textbook (Source) |Patient Specific |

|According to your textbook what is the signs and symptoms of the medical |C/O of sharp pain |

|diagnosis and nursing diagnosis |Denies any squeezing or suffocating sensation |

| |Location right upper chest with no radiation, no redness, bruising or injury |

|Pressure or aching in chest |noted in right upper chest. No masses or tenderness noted upon palpation. |

|Constrictive, squeezing, heavy choking or suffocating sensation |Pain last several hours, denies and nausea or vomiting |

|Location sub sternal with radiating into neck, jaw and down arms. |Pain occurs after eating |

|Pain lasts for only a few minutes (5 to 15 min) |Pain during activity and rest, no restriction in activity or ADLS |

|Pain occurs during activity or has a precipitating factor |Skin warm and dry, color pink |

|Pain at rest is unusual |Denies any shortness of breath, lungs clear to auscultation bilaterally. |

|Diaphoresis |Respiration regular and unlabored at 18 |

|Shortness of breath | |

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|Lewis, (p.772) |What is the assessment data, signs and symptoms that your patient exhibits. |

| |This is objective and subjective data. It also can be retrieved from the MD’s |

| |admission notes, History and Physical, Emergency Room record; admission nurses |

| |notes, patient, family and your assessment. |

Clinical Prep Sheet

Student Name: Nurse Nancy SVN Unit: 3-East Date: 01/01/2012 Clinical Wk#_1 Patient Initials: JDS Age: 86 Allergies: NKDA_________________________________

Nursing Diagnosis: Problem r/t etiology Refers to specific patient problem and need. NOT A MEDICAL DIAGNOSIS

|Short Term Goal |Met, Partial Met, Not Met and Analysis |

|Patient oriented, Realistic, Timed, and Measurable |Goal met patient wound healing without difficulty. |

| |If goal partial met or not met put why it was not met and what you plan to do. |

|Patient will have improved skin integrity BEOS (by end of stay) AEB decreased |Example goal not met wound healing not improving, review and revise plan of |

|redness and improved healing of stage 4 ulcer. |care with patient and team members. |

|Assessment Interventions |

|What you would assess and monitor with rationale: |

|Asses extremities’ for normal range of motion (limited movement can cause contractures) |

|Assess VS and LOC (changes in memory, orientation, etc could indicate neurological deficits: and change in VS could indicate infection, resp./cardiac distress)|

|Nursing Interventions: (Specific to Patient) |Evaluation of Interventions (Patient’s Response) |

|Intervention with rationale |Evaluations are patient oriented, not nurse oriented. There should be a patient|

| |response to the intervention performed. |

|Linen wrinkle –free/dry (moisture and wrinkles increase breakdown of the skin)| |

| |Skin remained free from further breakdown |

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|Avoid friction when moving patient (to prevent skin breakdown) |Used draw sheet-not friction or shearing of skin |

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|Reposition every 1-2 hours; get patient out of bed. (prolonged pressure on |Turned and reposition q2, no increased reddened areas. |

|bony prominences decreases circulation and increases skin breakdown) | |

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|Encourage ADLs ( to increase perfusion and circulation) |Patient assisted with ADLs |

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|ROM (passive and active) (increases circulation to prevent DVTS; maintains | |

|joint mobility and decreases development of contractures) |FROM in bilateral arms decreased range of motion in both legs. |

Patient Education and Health Maintenance:

Teaching Referral

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|Instruct active ROM exercises (see NI 5 above) |Physical Therapy (assists with physical needs, RIM, ambulating, equipment) |

|Evaluation: Patient demonstrated active ROM exercises |Home Health (assists with needs at home, bathing, medications, dressing change)|

Interventions should be problem specific and performed interventions are to be highlighted and an evaluation done.

Clinical Prep Sheet

Student Name: Nurse Nancy SVN Unit: 3-East Date: 01/01/2012 Clinical Wk#_1 Patient Initials: JDS Age: 86 Allergies: NKDA_________________________________

Therapeutic Communication (Must submit at least one (1) conversation per week – two exchanges)

Non Verbal Behavior Verbal Behavior Communication Technique Interpretation Evaluation

|Nurse – Pulled up chair along |“You seem upset about |Making Observation |I think the client appears |Ineffective – There were no |

|side of bed and leaned forward.|something.” |Therapeutic |upset. |feelings of anger expressed. I|

| | | |I thought I could get the |could have said, “You seem |

| | | |client to talk. |angry.” |

|Patient – Makes contact with |“I am” | | | |

|nurse. Shakes head yes. | | | | |

|Nurse – Facing the patient. |“Tell me more about your |Open ended question |I think the client is angry. |Effective – The client voices |

| |feelings.” |Therapeutic |I thought I had made her angry.|that she is scared and angry. |

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|Patient – Dries tears, looks |“I’m scared and angry.” | | | |

|angry. | | | | |

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Must submit one (1) communication interview per week. If you need more room you can continue on another CPS sheet.

Reflection of Clinical Week (What did you expect, what really happened? How do you think you are progressing? )

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|Reflect over your clinical week. Put you thoughts, experiences, and feelings. If you found a specific strength or weakness you discovered about yourself you |

|document here. State one thing you would have changed or done differently. |

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Clinical Prep Sheet

Student Name: Nurse Nancy SVN Unit: 3-East Date: 01/01/2012 Clinical Wk#_1 Patient Initials: JDS Age: 86 Allergies: NKDA_________________________________

CPS Medication Sheet

|Medication |Classification |Why is your client taking |Nursing Implications |Adverse Effects |

|Generic & Trade | |this drug? | | |

|Dosage & Route | | | | |

| | | |Most Serious implications and what |Minimum of 3 adverse effects. |

| | | |information you need as a nurse to | |

| | | |perform or assess before giving | |

| | | |medication. Minimum of 3 implications. | |

|digoxin Lanoxin |Cardiac Glycoside |CHF |1. Do not give if apical pulse less than|1. Nausea/Vomiting |

| | | |60. |2. Yellow Hazes |

|0.125 mg 1xday PO | | |2. Monitor digoxin level; electrolytes. |3. Dysrhythmias |

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| | | |3. Monitor for violent vomiting. | |

|furosemide Lasix |Loop Diuretic |CHF |1. I&O every shift, daily weight. |1. Hypokalemia |

|40mg 1xday PO | | |2. Monitor B/P, S/S overload/deficit. |2. Muscle cramps |

| | | |3. Monitor potassium level. |3. Decreased BP |

|captopril Capoten |ACE Inhibitor |Hypertension |1. Monitor B/P-do not give if less than |1. Dry cough |

|12.5mg every 8 hours | | |90/60. |2. Angioedema |

|PO | | |2. Monitor for orthostatic hypotension. |3. Bronchospasm |

| | | |3. Teach to take when BP is within a | |

| | | |normal range. | |

|potassium Cl K-Dur |Electrolytes |Electrolyte Replacement |1. Monitor K level (>5.8). |1. Muscle cramps |

|10 mEq 2xday PO | | |2. Monitor high potassium foods. |2. Bradycardia |

| | | |3. Store at room temperature. |3. Confusion |

|ibuprofen Motrin |NSAID |Muscle Pains |1. Take with food to minimize GI |1. GI Bleed |

|600mg every 6 hours | | |distress. |2.Hepatitis |

|PO | | |2. Take around the clock (ATC). |3. Increased bleeding time |

| | | |3. Advise to use sunscreen to prevent | |

| | | |photosensitivity. | |

v:\\vn level i\clinical\clinical prep sheet example 11/2012

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