PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET
I need help completing the Psycho/Social, Cultural/Spiritual needs, Growth & Development, Current Overall plan of care, Discharge plans and needs, Teaching needs, completing the medications sections, and putting in the normal lab values and its significance to the patient.
PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET
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Student Name: Gladys Mireku |
Week: 2 |
Dates of Care:5/20/2023 |
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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
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Attending physician/Treatment team: Ayman M. Jabr, MD
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Consults: No consult |
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Present Diagnosis: (Why patient is currently in the hospital) Headache and dizziness
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ER Management: (if applicable) Nile Township high school
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Allergies: Shrimp, Ibuprofen, Aspirin
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Code Status: Full code |
Isolation: (type and reason) none |
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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
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Communication needs: (verbal, nonverbal, barriers, languages) the patient has no communication barriers
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Past Medical History: (pertinent & how managed) Diabetes Mellitus Gerd Hypertension Obstructive Sleep Apnea Sciatica Spinal Stenosis Degenerative Joint Disease
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Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)
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Tests/Treatments/Interventions impacting clinical day’s care (include current orders)
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Assessments and interventions: (Include all pertinent data)
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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
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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)
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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)
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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 |
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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)
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Musculoskeletal: Activity: independent Traction: none Casts/Slings: Pertinent Labs/Test: Assessments/Interventions: (strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps
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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)
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Skin: Braden Score: Pertinent Labs/Test: Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)
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Pain: Pain score: 10 in the head Assessments/Interventions: acetaminophen was given (scale used, location, duration, intensity, character, exacerbation, relief, interventions) morphine
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Vascular Access: (IV site) Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)
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Gyn: Gravida/Para: none LMP: none Last Pap: none Breast exam: none Pertinent Labs/Test Assessment/Interventions: (bleeding, discharge) none
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Post-operative /procedural: Assessments/Interventions: none (immediate post procedure care)
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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)
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Advance Directives/Ethical considerations: DPOA: has no advanced directives Hospice:
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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 Collepals.com Plagiarism Free Papers Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers. Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS Why Hire Collepals.com writers to do your paper? Quality- We are experienced and have access to ample research materials. We write plagiarism Free Content Confidential- We never share or sell your personal information to third parties. Support-Chat with us today! We are always waiting to answer all your questions.  All Rights Reserved Terms and Conditions |