PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

Student Name: Gladys Mireku

Week: 2

Dates of Care:5/20/2023

Patient Initials

CV

Sex

M

Age

47

Room

837

Admitting Date

5/19/2023

Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

Intractable headache

Attending physician/Treatment team:

Ayman M. Jabr, MD

Consults:

No consult

Present Diagnosis: (Why patient is currently in the hospital)

Headache and dizziness

ER Management: (if applicable)

Nile Township high school

Allergies:

Shrimp, Ibuprofen, Aspirin

Code Status:

Full code

Isolation: (type and reason)

none

Admission Height:

165.1 centimeters (5,5)

Admission Weight:

107.9 kilograms (237 lbs)

Arm Band Location (colors & reasons)

on the right arm and it's white

Communication needs: (verbal, nonverbal, barriers, languages)

the patient has no communication barriers

Past Medical History: (pertinent & how managed)

Diabetes Mellitus

Gerd

Hypertension

Obstructive Sleep Apnea

Sciatica

Spinal Stenosis

Degenerative Joint Disease

Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)

Tests/Treatments/Interventions impacting clinical day’s care (include current orders)

Assessments and interventions: (Include all pertinent data)

Vital signs: (2 sets per day)

Time

8: 00

T

98.6

P

96

R

18

B/P

138/80

Time

13: 00

T

97.9

P

98

R

20

B/P

111/73

GI:

Diet: Regular

Swallow precautions:

Tube feedings:

NG / G tube:

Blood Glucose: (time & date)

Last bowel movement: (time & date)

Pertinent Labs/Test:

Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)

Respiratory:

02 modalities:

02 Saturation: 96

Suction:

Resp Rx’s:

Trach: none

Chest Tubes: none

Pertinent Labs/Test:

Assessments/Interventions: (Lung sounds, cough, sputum, SOB)

Neurosensory:

Neuro checks:

Alert & Orientated: x4

Follows commands: yes

Speech Comprehensible: yes

Pertinent Labs/Test:

Assessments/Interventions:

(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)

patient had dizziness and headache

Cardiovascular:

Telemetry:

Pacemaker/IAD:

DVT Prevention: heparin (5000 units)

Daily Weights:

Pertinent Labs/Test:

Assessments/Interventions:

(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)

Musculoskeletal:

Activity: independent

Traction: none

Casts/Slings:

Pertinent Labs/Test:

Assessments/Interventions:

(strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps

Renal:

Catheter (indwelling/external):

CBI:

Dialysis:

A/V access:

Pertinent Labs/Test:

Assessments/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O)

Skin:

Braden Score:

Pertinent Labs/Test:

Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)

Pain:

Pain score: 10 in the head

Assessments/Interventions: acetaminophen was given

(scale used, location, duration, intensity, character, exacerbation, relief, interventions)

morphine

Vascular Access: (IV site)

Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)

Gyn:

Gravida/Para: none

LMP: none

Last Pap: none

Breast exam: none

Pertinent Labs/Test

Assessment/Interventions: (bleeding, discharge) none

Post-operative /procedural:

Assessments/Interventions: none

(immediate post procedure care)

Safety:

Call light:

Bed Rails:

Bed alarms: no need

Fall risk: not at 4 risk

Assistive Devices: none

Sitter use: none

Restraints (type, duration & reason):

Assessment/Interventions (modifications to room, environment, Patient)

Advance Directives/Ethical considerations:

DPOA: has no advanced directives

Hospice:

Pertinent Data (Labs, X-rays, Etc.)

Results

Normal Lab Values

Significance to your patient

WBC

7.2

5.2-12.4

RBC

5.37

4.7-6.2

HGB

17.3

12.0-15.0

HCT

48.9

37-50%

MCV

91.0

95.3

MCH

32.3

27-31

MCHC

35.5

32-36

Platelets

207

151-401

RDW

14.5

12-15%

MPV

8.3

7-9

CBC

PT

INR

APTT

Glucose

225

70-99

BUN

14

7-25

Creatinine

0.86

0.6-1.3

Sodium

134

135-145

Potassium

5.3

3.5-5.2

Cloride

97

98-107

Calcium

9.0

8.6-10.3

T Protein

6.4

Albumin

3.8

SGOT

SGPT

Alk Phos

69

Magnesium

Amylase

Lipase

CPK

LDH

Cholestrol

CK

CK-MB

Troponin I

Myoglobin

LDI

Urinalysis

Color

Character

Spec. Grav.

pH

Protein

Glucose

Acetone

Bilirubin

Blood

Nitr

Urobili

RBC

WBC

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