Nursing Clinical assignment
Client’s information collected on day of clinical to assist with completing paperwork
Date: 1/28/21
Code: Full (No ACP docs)
Allegies: NKA
Diet: Regular
Weight: 117 lb
Vitals: T-97.7, P-70, R-18, BP-123/84, 02 sats 100 % RA
Principal Problem: Hip Fracture requiring operative repair, right, closed initial encounter (HCC)
PMH: Osteoporosis, Hypoglycemia, tobacco abuse
54-year-old female was walking outside and stubbled on piece of frozen ice and fell. Landed hard on right hip. A right hip comminuted fracture was identified and patient was admitted for surgical repair.
Doctor recommended intra medullary rod fixation of this fracture. Risk-benefit alternative and possible complication and treatment injury surgery were fully discussed.
Risk include but not limited to perioperative complication such as infection, blood clot, or even death.
Patient does have significant amount of osteoporosis at her young age, tobacco abuse also complicates this.
Patient underwent surgery and surgery was successful but doctor recommend that patient follow-up with family doctor to be back on her osteoporosis medication meanwhile she can also take some vitamin D and calcium.
Medications
Xarelto-anticoagulation
Enoxaparin-Prophylaxis
Scheduled Medications
1. 0900 -Sennoside-docusate sodium (SENOKOT-S) 8.6-50 mg 2 tabs oral daily
2. 099-Multivit, Ca, mineral-iron-Fe (THERAPEUTIC-M) 9 mg iron-400 mcg tab 1 tab oral daily
3. 099- Rivaroxaban (XARELTO) 10 mg daily
4. 0900-Sodium Chloride (saline lock flush) inj 2.5 ml intravenously BID as needed
5. 2000-Famotidine (PEPCID) 20 mg tab oral nightly
6. 0900-Magnesium hydroxide (milk of magnesia) 400 mg/5ml, 30 ml oral once daily
7. Hydrocodone-Acetaminophen (NORCO) 5-325 mg 1-tab Q4H PRN for moderate pain
8. Ondansetron (Zofran) 4 mg intravenously Q6H PRN for nausea and or vomiting
9. Hydromorphone (Dilaudid) 0.5 ml inj intravenously Q3H PRN for severe pain.
Dressing: unremarkable, dressing intact on right side. No drainage, no surrounding erythema. Dorsalis pedis pulse is present bilaterally and symmetric.
Review of system
General: patient is awake, alert, in no acute distress, no fever, no malaise or unexplained weight loss.
No cardiovascular, pulmonary, endocrine or hematological disorders. Has very good functional capacity w/o symptoms. Worked as a waitress most of her life, able to walk and climb stairs easily w/o symptoms before current fall.
Labs:
COVD-19 -Negative
Glucose -98
Sodium-135
Potassium-3.3
CO2-25
BUN-6.0
Creatinine-0.06
Calcium-8.2
Magnesium 2.0
Total Protein-6.5
AST/SGOT-19
WBC-6.3
RBC-3.72
HCT-34.9
Plates-154
Hematocrit-34.9
Hemoglobin-11.0
Patient Preparation/Case Study 5 pts
Room:
Name:
Age/Sex:
Surgical Day:
Admit Date:
Code:
Allergies:
Isolation:
Diagnosis:
Activity:
PMH:
Vitals:
O2
Pain
BS
Medications Time:
Diet:
% Eaten:
Diagnostics:
Fall Risk:
Last BM:
Report/Notes:
IV:
Labs:
Start Date:
Flu
id and Rate:
Change Date:
Intake:
Total for Shift________
IV:
PO:
Therapies:
PT
OT
RT
Treatments:
Immunizations Status
Output: Total for shift ________
Urine:
Drains:
Emesis:
Education Needs:
Health Promotion
Pre-Clinical Nursing
Assessment
:
(from the client chart) 5 pts
|
Neuro: Pain Assessment: |
Cardio/Tele Edema |
Resp: Lungs/O2: |
GI: |
GU/Repro: |
|
|
Behavioral Health: |
DVT Prophylaxis: |
Skin: Braden Score: |
Notes: |
Current Nursing Assessment: (during this shift) 5 pts
|
Neuro:
Pain Assessment: Pain interventions: Pain Reassessment: |
Cardio/Tele Assessment: Edema Vitals: |
Resp: Assessment: O2: |
GI: Assessment: Last BM: Intake: |
GU/Repro: Assessment: Output: |
|
Skin: Assessment: Wound/dressing: Dressing Change: Braden Score: |
Misc: |
Pre-Clinical Prep-Pharmacology: 10 pts
List each medication you will administer this shift and PRNs in last 24 hours (10 pts)
|
Medications: Generic/Trade , Route, dosage, Time |
Pharm. Class: |
Mechanism of Action In OWN WORDS: |
MOST Common Side Effects: |
Nursing Responsibilities: Include assessments needed and special administration instructions |
Client Name: __________________ Age: __________y/o M/F Admitted: ________Room # _______Doctor _________ FULL CODE/DNR 5 pts
|
S Situation |
||
|
B Background |
PMH: Dm / CHF / HTN / CAD / PCI / Liver dz / PVD / GERD / COPD / Asthma / CKD / ERSD / Smoker Drug Abuse / Psych / CVA / Dementia / Hypothyroid / CA /_________ |
|
|
Tests: MRI / X-ray / CT/ Echo EF: ____ / Endo / US / Cath Results of tests: |
||
|
A Assessment Contact: MRSA C – Diff ESBL Flu COVID Droplet Neutropenic Need: Urine Cx Resp Cx Flu Swab COVID Swab MRSA Swab Extras: Daily Weight Strict I &O Fall Risk Observation 1:1 Sitter NPO @ Midnight |
IV # _______ R / L SL Date: __________ Site AC / FA / Hand/ Wrist / UA Central: IJ / PICC / Port / Dialysis |
IVF NS / ½ NS / D5 ½ / D2 NS / LR / Abx IV Rate: _______ ml/hr Drips: heparin / blood / TPN / diabetic / Cardiac |
|
Neuro: AXO x _____ / Confused Activity: Up ad lib / 1 / 2 / Bed-rest Walker / Cane Neuro Checks / Restraints / Bed Alarm |
Pain: Level Location: Medication: Frequency: |
|
|
Respiratory O2 @ _____ L NC / RA / NRB / CPAP / BIPAP Trach Breath Sounds: Clear / Diminished / Wheezing / Crackles / Course Cough Productive / non-productive Treatment: Nebs / IS / CPT |
Vital Sign Trends HR Temp BP RR O2 |
|
|
Cardiovascular SB / NSR / ST / A fib / A flutter / A paced / V paced/ PVC / PACs/ AICD / Murmur / Block Edema none / Gen / Trace / 1+ / 2+ / 3+ Pitting / non-pitting R / L/ Bilateral Arms/Leg Pulses DP Radial Dopplers / +1 / +2 |
VTE Prophylaxis SCDs / Foot Pumps Heparin / Lovenox Coumadin / Xarelto Eliquis / None Needed Needs Other |
|
|
Gastrointestinal Diet Reg / Clear / Full / AHA / ADA / Dysphagia I II III / Soft / Renal / NPO Hypo / Active / Hyper / Nausea / Vomiting / Diarrhea G-tube (LWS / Gravity) / Ostomy Last BM ______ |
Genitourinary Voiding / Foley / Incontinence / Anuria Clear / Cloudy Yellow / Amber / bloody BR / Urinal / Bedside comm / Bedpan Dialysis: M Tu W Th F Sa Sun |
|
|
Musculoskeletal Weakness: RUE / LUE / RLE / LLE Numbness: RUE / LUE / RLE / LLE |
Skin: (Wounds & Dressings) |
|
|
BG Monitoring AC&HS ? Q6h / Q ___h |
Labs: |
|
|
Drains: Chest Tube / JP / Hemovac / Wound Vac R / L Level: _______ Serosanguinous/Sanguineous |
||
|
R Recommendation |
Scheduled Procedures: Cath / US / Stress / Echo / Dopplers / MRI / CT Consults: PT / OT / GI / Cards / Neuro / Nephro / Wound / Ortho / Psych / Pulm / Surg Discharge to: Home / Home Health / Assisted Living/ Nursing Home/ Rehab Discharge Day: ___________ |
Put it All Together to Think Like a Nurse (complete this during your shift)
1. What data did you collect from the medical record and the patient that is RELEVANT to the nurse? 1 pt
|
RELVEVANT Data: |
Clinical Significance: |
2. Identify data gaps. What did you not find out about your patient that would be useful for their ongoing care?1 pt
|
Data Gaps: |
3. What problems might you see in your patient/identify the most likely problems. Why might you see those problems? Rank them in order of priority. What additional data would be needed relevant to the problem?1 pt
|
Patient Problems: |
Why: |
Rank: |
Additional Data Needed: |
4. Using your identified problems this shift, what is the physical nursing priority and priority interventions to advance the plan of care? 3 pt
|
Nursing Priority: |
|
|
Outcome (SMART Goal) |
|
|
Interventions: |
5. Using your identified problems this shift, what is the psychosocial nursing priority and priority interventions to advance the plan of care? 3 pt
Nursing Priority:
Outcome (SMART Goal)
Interventions:
6. Education Priorities/Discharge Planning: What educational/discharge priorities were taught to your patient during your clinical day? 1 pt
|
Education PRIORITY: |
|
|
Priority Topics to Teach: |
Rationale: |
NURS 2290 Case Study
Student: _______________________________________ Date care was provided:__________________
Directions: Complete this case study on your assigned client. You will submit your preclinical preparation form with this case study. This form is due one week after you have cared for the client. Use APA citation every time you look up information from a resource. Include a reference list.
1. Pathophysiology of primary health concern. 3 pts
What is the reason for the client hospitalization? ______________________
Describe the disease process in your own words.
What is the recommended treatment for this condition? (include citation where you got this information).
2. Complications. 3 pts
Identify any complications that your client developed during this hospitalization?
What potential complications is this patient at risk for?
What interventions will help prevent complications?
3. Safety. 3 pts
What threatens this patient’s safety at this time? What can you do to protect him/her? Is client aware of safety concerns?
4. Priorities/Care Plan
Your priorities may have changed after you cared for your client (or it may be the same as you identified prior to patient care). Identify two priority physical problems and one psychosocial priority.
8 pts
|
#1 Nursing Priority Physical Problem you identified during your clinical day: |
||
|
Data that supports this as your priority: |
||
|
Defend why you selected this as top priority. |
||
|
Expected Patient Outcome (written as a smart goal): |
||
|
Priority Nursing Interventions Rationale (include citation) (Include at least 5 1. 1. 2. 2. 3. 3. 4. 4. 5. 5. |
||
|
Evaluation of Expected Patient Outcome: |
||
|
Has the overall status of the patient improved, declined, or remain unchanged? What changes would you make to your plan of care to assist the patient in meeting the expected patient outcome? |
||
|
#2 Nursing Priority Physical Problem you identified during your clinical day: 8 pts |
||
| Data that supports this as your priority: | ||
| Expected Patient Outcome (written as a smart goal): | ||
|
Priority Nursing Interventions Rationale (include citation)
(Include at least 5) 1. 1. 2. 2. 3. 3. 4. 4. 5 5. |
||
| Evaluation of Expected Patient Outcome: | ||
| Has the overall status of the patient improved, declined, or remain unchanged? What changes would you make to your plan of care to assist the patient in meeting the expected patient outcome? |
|
#1 Nursing Priority Psychosocial Problem you identified during your clinical day: 8 pts |
5. Patient Education: 3 pts
What did you teach your client during your clinical shift?
What methods did you use to teach the information?
Identify factors that could/did affect your client’s ability to learn.
How did you evaluate if the client understood what you taught?
Identify other topics that would have been appropriate to teach this client?
6. Health Promotion: 3 pts
What does the client do to stay healthy?
What goals does the client have to improve their health?
What suggestions could you give the patient to promote health?
7. Growth and Development: 3 pts
Identify the developmental stage of your client according to Erikson. ________________
How does the developmental stage of your client impact the care that you provide?
8. Cultural Issues/Social Roles 3 pts
Identify the various groups that this client is a member of. How will this hospitalization effect the client in fulfilling his/her social role? Are there any cultural norms that the nurse should be aware of to provide holistic care?
9. Ethics/Legal 3 pts
Identify potential or real ethical issues that could or did occur?
10. Discharge Plan: 3 pts
Discuss discharge plans and needed referrals.
11. Journal Article: 3 pts
Find a journal article that applies to the care of this client. Article must be an evidenced based article from a medical/nursing journal, written by a healthcare provider, and is less than five years old. You must either attach the article or provide a working link to the article.
How could you use the information in this article to validate the care that was provided or make suggestions to improve care?
12. Self-Reflection: 4 pts
What did you learn today that you can apply to future patients you care for?
What did you do well today?
What could you have done better?
What is your plan to make any weaknesses a future strength?
13. APA 2 pts
Citations were completed appropriately. Reference list correctly done.