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

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
College pals.com Privacy Policy 2010-2018