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Clinical WorkSheet - Template

Clinical WorkSheet - Template

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Published by: Rene Contreras on May 04, 2011
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RNSG 1262 Nursing Case Study

Student Name: _________________________________________ Dates of Care: _______________________ Client Initials: ________ Gender: _____ Age: ____ RM# _____ Med Team/MD: ___________________ Admitting Diagnosis: _______________________________________________ Date of Admission: __________________ Concurrent Diagnoses: ___________________________________ Surgery: ________________________ Date: ______________ Allergies to Drugs or Foods: _____________________ Advanced Directives / Code Status: ______________

Therapeutic Modalities/ MD Orders:
Data Collection Day Vital Signs/SpO2: Frequency I & O/ Fluid Restrictions Diet Scheduled Diagnostics Activity Level Dressing Change Orders Resp. Therapy Physical Therapy Daily Weights SCD, TEDS, CPM Accuchecks Daily Labs: Other Treatments: Clinical Day 1 Clinical Day 2

Summaries of Progress Notes:
Doctor¶s Data Collection Day Doctor¶s Data Collection Day #1 and or Day #2 Nurse¶s Data collection Day Nurse¶s Data Collection Day #1 and/or Day #2

Pathophysiology of Admitting Diagnosis:

Pathophysiology of Concurrent Diagnoses:

Description of Surgical Procedures:

5 Hct 41-53 Platelets 150-450 ESR N/A Differential Other: MCV MCH MCHC RDW Mean Platelet Chemistry: Na K Cl Glucose Total Protein Albumin CO2 BUN Cr Calcium Other: Bilirubin Total Bilirubin Direct ALT AST Mg Phos Alk Phos Lactic Acid (Plasma) Anion Gap 30-98 26-34 31-37 12.2 2.2 5-19 .5-17.0-14.2-1.0-0.0 20-29 7-25 0.6 6.2-10.2-8.60 8.7-1.2 135-145 3.1 3.5-5.1 94-106 60-100 6.8-10.6-2.90 Hg 13.6 32-108 0.5-5.highlight abnormals Labs/X-rays/Dx Tests Results Normal Range Date Result Date Result Date Result Correlation to Pathophysiology: Interpret results as well as correlating with the client¶s medical condition: Complete Blood Count: 3.Lab Data Sheet .6-11.3 0.5-5.0 WBC RBC 4.2 0.4 0-35 0-38 1.5-2.4-4.

2 PT PTT Urinalysis: Clarity Color Bilirubin Blood Glucose Ketones Leukocytes pH Protein Sp Gravity Urobilonogin Microscopic: WBC RBC Epithelial Bacteria Casts UDS Amphetamine Barbituate Benzodiazapine Cannabinoids Opiates PCP Cocaine Negative Negative Negative Negative Negative Negative Negative ---------Negative Negative Negative Negative Negative 5-8 Negative 1.0-28.35-7.035 22-37 0-1mg/dL 0-5 HPF 0-5 HPF 0-5 HPF 0-450 HPF 0-1 Arterial Blood Gases: 7.8-1.Coagulation Studies: INR 0.0 HCO3 Culture & Sensitivity: note source/growth and sensitivity Exudate Culture Gram Stain -------------- Fungal Calcaflour -------- .45 pH 32-48 PCO2 83-108 PO2 ----O2 sat 21.0011.

Radiological Studies: X-Ray .Antigen Hep B.Chest Sonogram Extremity CAT Angiograph EKG: Diagnostic Tests: describe results Vancomycin Level Blood Antibody Screen Immunology Hep B.Antibody Hep A Hep C ------ Non Reactive Non Reactive Non Reactive Non Reactive .

Trade Name Generic Name Pharmacological Class Mechanism of Action Dose/Route Max Dose Rationale for this client Major Side Effects Nursing Implications for Safe Administration and Evaluation of Therapeutic Effects y y y y .

Trade Name Generic Name Pharmacological Class Mechanism of Action Dose/Route Max Dose Rationale for this client Major Side Effects Nursing Implications for Safe Administration and Evaluation of Therapeutic Effects y y .

Trade Name Generic Name Pharmacological Class Mechanism of Action Dose/Route Max Dose Rationale for this client Major Side Effects Nursing Implications for Safe Administration and Evaluation of Therapeutic Effects y y .

Trade Name Generic Name Pharmacological Class Mechanism of Action Dose/Route Max Dose Rationale for this client Major Side Effects Nursing Implications for Safe Administration and Evaluation of Therapeutic Effects y y y y .

Trade Name Generic Name Pharmacological Class Mechanism of Action Dose/Route Max Dose Rationale for this client Major Side Effects Nursing Implications for Safe Administration and Evaluation of Therapeutic Effects y y y y .

Trade Name Generic Name Pharmacological Class Mechanism of Action Dose/Route Max Dose Rationale for this client Major Side Effects Nursing Implications for Safe Administration and Evaluation of Therapeutic Effects y y y y .

Physical Assessment . 3+ indentation. 1 = doppler. ______ Reaction: __________ Vision Impairment: Y N Describe: ___________________________________ Glasses: Y N Musculoskeletal Motor Strength: 0 = complete paralysis.Data Collection Day Neurosensory Level of Consciousness: Oriented: Confused: Lethargic: Alert: Unresponsive: to Verbal stimuli Y N Painful Stimuli: Y N Glasgow /coma Scale Rating (if needed) ______ Place Time Disoriented: Person Behavior: _________________________ Communication/Speech Pattern: ______________ Pupil size: Rt. 1= flicker of movement. 2 = overcome gravity. 5 = wheezing. 3 = crackles. 4+ indentation = > 10mm RUE ____ LUE ____ LLE ____ RLE _____ Periorbital_____ Sacral______ JVD: : Y N History or current alterations affecting this system: History or current alterations affecting this system: Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx: . 6 = friction rub. N = normal. 2 = weak.L= Limited Activity/ Restrictions: _________________________ ___________________________________________ Risk for Fall: : Y N Chest inspection (expansion. 3 = 50% of normal 4= 75 % of normal strength. deformities): _________ ___________________________________________ ___________________________________________ Use of accessory muscles: yes ___ no: __ Lung Sounds: 1 = clear. RUL ___ RML __ RLL _____ LUL ___ LLL_____ O2 saturation: Room Air:___ ______ On Oxygen Therapy:________ Respiratory Respiratory Rate: ____ Pattern: _____ Normal _____ Shallow _____ Rapid_____ Labored_____ Cough: Non ±Productive ___ Productive ___ Describe:___________________________________ ___________________________________________ Sensation: Intact Losses Describe:___________________________________ Hearing loss: : Y N Describe:___________________________________ History or current alterations affecting this system: Sedative medications Use of Assistive Devices: ___________________________________________ ___________________________________________ ______________________________ History or current alterations affecting this system: History or current alterations affecting this system: Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx: Cardiovascular: Apical pulse: ____ irregular Rhythm: regular Heart Sounds: Aortic _____Pulmonic ______ Tricuspid _____Mitral ______ Describe abnormalities: ______________________ ___________________________________________ Capillary Refill: < 3sec > 3 sec. HA= hyperactive. 3 = normal and 4 = bounding ___RR __LR ____RDP ___LDP ___ RPT ___LPT Y N Condition: _______ Dialysis Shunt: : ___________________________________________ Homan¶s sign: ____ Positive ____ Negative N/A Edema: describe as 0=none. 4 = rhonchi. 1+= barely detectable. 5= 100% of normal strength RUE ____ LUE ____ RLL ____ LLE ____ Describe:__________________________ Mobility: ____________________________ ___________________________________________ ROM . 2+ indentation. 2 = diminished. Gastrointestinal Abdomen: distended non-distended Bowel Sounds: describe as A = absent. ______ Lt. HO= hypoactive ___ RUQ ___RLQ ___LUQ ____LLQ Last BM: __4/10/11___(date) diarrhea _____ constipation ____ normal__x___ Y N Ostomy: Type/describe fistula: _________________________ __________________________________________ N/G decompression: : Y N Describe: ___________________________________________ ___________________________________________ Y N Feeding tube/PEG: : Feeding type/rate: ____________________________ Patency/Residual:____________________________ History or current alterations affecting this system: Genitourinary Patterns: continent ___ incontinent ___ nocturia___ ___ frequency ___ urgency ___ dysuria _____ urinary retention ___ Appearance: clear ___ cloudy ___yellow ___ pink ___ amber ____bloody____ Catheter: : Y N Type-____________________________________ 24 hour I&O______________________________ Pulses: describe as 0 = absent.

Integument Temp: ___warm. ___ cyanotic. ___ flushed ___ Other (describe)______________________________ Skin Condition:_____normal__________________ ___________________________________________ Incision/wounds:(describe)_____________________ ___________________________________________ ___________________________________________ Dressing Orders:______________________________ ___________________________________________ ___________________________________________ Braden Scale Score: _____ PUSH Tool Score: __________ Nutrition Adm. ___moist. and IV medications . ___cool Moisture: ___dry. Weight: ________ Current Weight:_______ Ideal Body Weight:____ History of Weight loss: ________________________ ___________________________________________ Diet History: ___ _____________________ ___________________________________________ ___________________________________________ Appetite:____ _________________________ Percent of meal eaten: Breakfast:________ Lunch:_________ Dinner: _________ Snacks:_____________________________________ Describe condition of teeth/denture/oral mucosa: ___________________________________________ ___________________________________________ ___________________________________________ Other: _____________________________________ Blood glucose monitoring: Reading/time ______________ Reading/time_____________ Pain Assessment (describe) Type of Pain: Acute______ Chronic____ Location: ________________________ Intensity/Rating:_____________________________ Pattern: ____________________________________ Nature : ______________ ___________________________________________ ___________________________________________ ___________________________________________ History or current alterations affecting this system: History or current alterations affecting this system: History or current alterations affecting this system: Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx: List all scheduled. ___ pale. ___hot. prn. ___diaphoretic Color: ___normal.

Physical Assessment .Data Collection Day of Care# 1 Neurosensory Musculoskeletal Vital Signs:__________________________ Respiratory History or current alterations affecting this system: History or current alterations affecting this system: History or current alterations affecting this system: Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx: Cardiovascular: Gastrointestinal Genitourinary History or current alterations affecting this system: History or current alterations affecting this system: History or current alterations affecting this system: Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx: .

Integument Nutrition Pain Assessment:(describe) History or current alterations affecting this system: History or current alterations affecting this system: History or current alterations affecting this system: Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx: Wound / Surgical Incision Assessment: Assessment Wound #1 Type of wound and Stage Location Length Width Depth Drainage Odor Undermining / Tunneling Wound bed tissue type Wound #2 Wound #3 Factors affecting wound healing: Miscellaneous Information: .

Physical Assessment .Data Collection Day of Care# 2 Neurosensory Musculoskeletal Vital Signs:___________________________ Respiratory History or current alterations affecting this system: History or current alterations affecting this system: History or current alterations affecting this system: Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx: Cardiovascular: Gastrointestinal Genitourinary History or current alterations affecting this system: History or current alterations affecting this system: History or current alterations affecting this system: Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx: .

Assessment Wound #1 Wound #2 Type of wound and Stage Location Length Width Depth Drainage Odor Undermining / Tunneling Wound bed tissue type Wound #3 Factors affecting wound healing: Miscellaneous Information: .Integument Nutrition Pain Assessment:(describe) History or current alterations affecting this system: History or current alterations affecting this system: History or current alterations affecting this system: Possible Nursing Dx: Possible Nursing Dx: Possible Nursing Dx: Wound / Surgical Incision Assessment: Document changes for day two.

Include positive/negative resolution and justify your conclusion. Understanding of Illness/Treatments Psychosocial Diagnosis: Community Referral .Assessment Data: Psychosocial/ Cultural Stressors: Behaviors/Coping Strategies Identified culture/ethnicity Religion Occupation Family Role Developmental Task: Clients Developmental Task According to Erikson: Describe if the client has/has not achieved their developmental task.

Nursing Dx Priority_1__ Hospital Outcome/Goal: Nursing Interventions: Designate I: independent D: dependent C: collaborative/interdependent Scientific Rationale Evaluation (Specify as goal met/unmet/or partially met) Nursing Diagnosis/Analysis: y y Correlation to Patho or Psycho-physiology Discharge Goal: Teaching Plan: .

Correlation to Patho or Psycho-physiology Discharge Goal: Teaching Plan: .Nursing Dx Priority___ Hospital Outcome/Goal: Nursing Interventions: Designate I: independent D: dependent C: collaborative/interdependent Scientific Rationale Evaluation (Specify as goal met/unmet/or partially met) Nursing Diagnosis/Analysis: y y .

Nursing Dx Priority____ Hospital Outcome/Goal: Nursing Interventions: Designate I: independent D: dependent C: collaborative/interdependent Scientific Rationale Evaluation (Specify as goal met/unmet/or partially met) Nursing Diagnosis/Analysis: y y Correlation to Patho or Psycho-physiology Discharge Goal: Teaching Plan: .

Dx Priority____ Hospital Outcome/Goal: Nursing Interventions: Designate I: independent D: dependent C: collaborative/interdependent Scientific Rationale Evaluation (Specify as g partially met) Diagnosis/Analysis: y y on to Patho or Psycho-physiology Teaching Plan:. e Goal: .

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