PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET
| Student Name: | Week: 4 | Dates of Care: 2/4/2022 |
| Demographics and Brief History | |||||
| Patient Initials M D | Sex F | Age 13 | Room 281 | Admitting Date 2/12022 | Admitting Chief Complaint: What symptoms cause the patient to come to the hospital? Depression. Suicidal ideation without a plan |
| Attending physician/Treatment team: | Precautions: Suicidal precaution | ||||
| Primary Diagnosis: Major depressive disorder, recurrent, severe without psychotic symptoms. Anxiety disorder unspecified F 41.9 | Co-morbidities: Suicidal ideation, depression, and anxiety | ||||
| Allergies: No known allergies | Code Status: Full Code | Isolation: (type and reason) There is no isolation | |||
| Admission Height: 60.98 in | Admission Weight: 40.801 kg (89.0 lbs.) | Arm Band Location (colors & reasons) No arm-band | |||
| Past Medical History: (pertinent & how managed) | |||||
| Significant Events during this hospitalization but not during this clinical time: (examples include restrictive interventions or any medical emergencies. Include date, event and outcome) | |||||
| Physical Assessments and Interventions: (Include all pertinent data) | |||||
| Vital signs: Time T 98.7 97 P 90 95 R 16 18 B/P 125/89 115/63 | |||||
| General Appearance · Grooming/Clothing · · Hygiene · · Posture · · Gait · · Obese/average or normal/ underweight · · Evidence of scars/ abrasions/ bruises/ tattoos/ or other physical markings · | Activities of Daily Living · Sleep/rest · · Diet · Regular · Eat 76% of her food · Exercise/mobility · · Elimination · · Hygiene · | ||||
| GI Diet: Blood Glucose (time & date): Last bowel movement (time & date): Pertinent Labs/Test: Assessments: · Stool · · Bowel sounds · · Tenderness, distention · · Appetite, nausea, vomiting · Interventions: | Respiratory: Assessments: · Lung sounds · · Cough, sputum · · SOB · Interventions: | ||||
| Neurosensory: Alert & Orientated: Follows commands: Speech Comprehensible: Pertinent Labs/Test: Assessments: · LOC · · Pupils · · Glascow Coma Scale · · Dizziness · · Headaches · · Tremors · · Tingling, weakness, paralysis, or numbness · Interventions: | Cardiovascular: Pertinent Labs/Test: Assessments · Peripheral pulses · · Heart sounds (murmurs or bruits) · · Edema · · Chest pain, discomfort, palpitations · Interventions: | ||||
| Musculoskeletal: Activity: Casts/Slings: Assessments: · Strength, weakness · · ROM · · Gait (documented under appearance) · Pain · · Fractures, amputations, or transfers · Interventions: | Renal: Pertinent Labs/Test: Assessments: · Bruit, thrill, location · · Urine-quality · · Burning with urination, hematuria · · Incontinent, continent, I & O · Interventions: | ||||
| Skin: Braden Score: Pertinent Labs/Test: Assessments · Bruising, wounds, drains · · Turgor · · Surgical incisions · · Finger & toe nails · Interventions: | Pain: Pain score: Assessments/Interventions: · Scale used · · Location, duration, intensity, character · · Exacerbation, relief · Interventions: · | ||||
| Gyn: Gravida/Para: LMP: Last Pap: Breast exam: Pertinent Labs/Test: Assessment · Bleeding · · Discharge · Interventions: | Safety: Bed Rails: Bed alarms: Fall risk: Assistive Devices: Interventions: · | ||||
| Advance Directives/Ethical considerations: AD: POA: | |||||
| Lab Values Results Normal Lab Values Significance to your patient (if applicable) WBC 8.1 RBC 4.15 HGB 10.8 HCT 31.6 MCV 76 MCH 26 MCHC 34.2 Platelets 293 RDW 14.0 MPV None Glucose 100 BUN 14 Creatinine 0.5 Sodium 137 Potassium 3.5 Cloride 104 Calcium 9.9 Salicylate None Please add lab values for any medications that may require a blood draw (e.g., Lithium, Lamotrigine, Carbamazepine, Oxcarbazepine, Sodium valproate/divalproex sodium) Lab Value Results Normal Lab Values Significance to your patient (if applicable) 10 Panel Toxicology/Drug Screen: if available Lab Value Results Normal Lab Values Significance to your patient (if applicable) Utox Negative Urine Negative Blood Alcohol Level/Ethyl Serum Level: if available Lab Value Results Normal Lab Values Significance to your patient (if applicable) | |||||
| Psycho/Social Assessment |
| · Level of education · · Occupation · · Race/Ethnic Background or Identification · · Religion/Spiritual Beliefs · · Communication needs: (verbal, nonverbal, barriers, languages) · · Special Talents/Interests/Skills · · Environment (home and community) · · Family Structure/History: |
| Stage of Development: (Erikson’s Stage of Development, describe the current stage of the client and previous stages that the client may not have successfully completed) |
| Support System: |
| Stressors/Stress Management Practices: |
| Pathophysiological Discussion: One scholarly article must be cited using APA format in this section. The textbook may also be used as a secondary source. The reference list should be included with the summary of the article. |
| Discuss the current disease process: |
| Discuss the etiology of the patient’s illness: |
| Also note the complications that may occur with treatments and patient’s overall prognosis: |
| Attach a research article pertaining to diagnosis of patient. Write a summary about the article below and include a reference list: . References |
1
| Medications | Classification | Dose | Route | Freq | Purpose/Mechanism of Action | Significant Side Effects / Adverse Reactions | Nursing Implications |
| (Tylenol) Acetaminophen | 650 mg | PO | Q4H PRN | ||||
| Al Hydrox/Mg Hydrox/Simethicone | 15 ml | PO | Q6H PRN | ||||
| Magnesium Hydroxide | 15 ml | PO | Daily PRN | ||||
| Escitalopram Oxalate | 5 mg | PRN | Nightly | ||||
Nursing Process Section
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Write My Essay For MeNursing Diagnosis:
List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting.
| Priority | Nursing Diagnosis | Related to | As Evidence By | Rationale (reason for priority) |
| 1 | ||||
| 2 | ||||
| 3 | ||||
| 4 |
Complete a table for the top two priorities listed in the table above. A minimum of 3 interventions are required for each nursing diagnosis, and one intervention must be an individual patient teaching and one must include a teaching for the patient’s family/caregivers (if applicable- i.e., patient is not homeless and/or has no family).
| Table for Nursing Diagnosis Number 1 | |||
| Assessment · Signs and symptoms relative to the nursing diagnosis, as evidence by · 2 objective · 2 subjective | Patient Outcome · SMART · Specific · Measurable · Attainable · Realistic · Timely | Interventions/Implementations · Includes interventions/ nursing actions directly relating to pt. outcomes · Specific in action, frequency and contain rationale · Minimum of 3 interventions appropriate to help pt./ family meet their outcomes | Evaluation · Includes all data that is listed as criteria in outcomes · Outcomes are determined to be met, partially met, or not met · If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set |
| Table for Nursing Diagnosis Number 2 | |||
| Assessment · Signs and symptoms relative to the nursing diagnosis, as evidence by · 2 objective · 2 subjective | Patient Outcome · SMART · Specific · Measurable · Attainable · Realistic · Timely | Interventions/Implementations · Includes interventions/ nursing actions directly relating to pt. outcomes · Specific in action, frequency and contain rationale · Minimum of 3 interventions appropriate to help pt./ family meet their outcomes | Evaluation · Includes all data that is listed as criteria in outcomes · Outcomes are determined to be met, partially met, or not met · If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set |
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