Fall rik Modena 35 Clinical Assessment Form N414 Student Name: Clinical Date; ‘Assigned Unit: lle rh4 aan icy ee; Gender: | Admission date: | Resuscation Status 154 F__| jojo} 4 full "admit weight: Height: 4 \ol ca “hilar ARRLe curds , Increased Pan and evytivawa, cnetling eae Puss - Necatzing Faccitis. LLE ae Sr YIN Depression Past surgealhtoy No Sugical Hx on file History of present illness: PAM - Dialoetes- chyonle fort wounds Sepsis - neorotrivig Fiscitis LLE - Fever A lactate Wypoglacermia > trypotensive KEK Wik UG > deloride tant wud voc —> avtoqvagh placemat Laboratory Values: Complete the table with applicable lab values, for the results/trend indicate If value is increased or decreased from previous result NORMAL DATE/TIME RECENTRESULT REASON FOR ABNORMAL VALUE ee ne An pores eraProne COMPLETE BLOOD COUNT 10/24 (cBc) ug White blood cells (WBC) 4.5-II os ual WNR ed bod el (RE) 40-54) Wa al ieee Binap licen bin (Heb) LLIN a ae \aelte eee $0 4 Elid ouarec peeote 35-4 We | 09.4 [EROATISS yo as (50-40 PBL 925 WHRCHEMISTRY STUDIES ‘Sodium (Na) Potassium (K) ‘Chloride (Cl), uc Hemoglobin AIC _Choletaal Blood Urea Nitrogen (BUN) Creatinine Albumin Calcium (Ca) Phosphorus COAGULATION Prothrombin time (PT) International normalized ratio (INR) Partial thromboplastin time (PTT) LIVER FUNCTION Bilirubin Alkaline phosphatase ALT (alanine aminotransferase) AST (aspartate aminotransferase) NORMAL < \ lab j6, RT 36-5 RG DATE/TIME 1-07 Seas (00-10 (9-20 VFR BY = 104 14-25 4&2 20-34see "Caos 1/4 02%. NA Tej24 OuDy (o/24 002% \oly tah 10.4 OFM og be {0/4 oail NK NA NA Ni RECENT REASON FOR ABNORMAL VALUE AND RESULT POTENTIAL SYMPTOMS Ulu wNR 5.4 Be 942 WNR IB + hypeglugemnia (dictoeles) V7 wR 674 wwe 84 WN 3.4 NNR ss avfavin Weasvye Wwe 4 Mnevenced Clothing bi meADDITIONAL LABS cK at Troponin ‘S-natriuretic peptide (BNP) Ammonia Arterial Blood Gas (ABG) pil peo2 7002 Hoos Grleveonale ‘Oxygen saturation (S202) NA NA NA NA NORMAL DATE/TIME "RECENT REASON FOR ABNORMAL VALUE AND ~ RESULT POTENTIAL SYMPTOMS TRB oh Towne 45 MNS ues WN Beato: ELT taqo4 a sed 5 Mee tes 2 fe eS ETAT Bo-to0 2A 9 we Lacie Acid oy lactate Allergies: ._ | Type of Reaction: Sulfancetnoazne W-Trinucthoprim | tives Doxy cicline N/V Tvamode! Niv Invasive Lines Peripheral IV Access Site Assessment ves [NO |} \Vsite and catheter gauge: WV dressing dry, no edema, redness of site IV site and catheter gauge: IV dressing dry, no edema, redness of site IV site and catheter gauge: IV dressing dry, no edema, redness of site IE : Central Access (CVC) ‘Site Assessment YES | NO Central line site: | # of lumen: Alcohol caps present (if used) | Uh budlic} 9.Indication for line: Dressing dry and intact, OK acess yes Central Access (CVC) ‘Site Assessment Yes [NO Central line site: # of lume Alcohol caps present (if used) | indication or line: Dressing dry and intact ‘Arterial Access Insertion Site/Pressure Bag Assessment YES | NO ‘Recess site: Dressing dry, no edema, redness of site Pressure bag fully inflated, Bag fluid (NS), assessment of volume remaining, and zeroing of transducer ‘Recess ste: Dressing dry, no edema, redness of site Pressure bag fully inflated, Bag fluid (NS), assessment | of volume remaining, and zeroing of transducer Physical Assessment Glasgow Coma Assessment ye opening response ay | Verbal response ‘Score oe Motor response Soe Ly Additional comments for any abnormalities: © For any GCS <15, please note specific criteria that was abnormal.Pupil Assessment ae a S| Additional comments for abnormal assessment findings: Right pupil size Sizes mm Left pupil size Size: mim PERRIA pe eat Neurological = LOC: Describe orientation Able to follow commands ey No] Grip equal, bilateral (5) No Sensation intact to all extremities (WES-NO| Speech clear YES] NO Sensory deficit hearing vision, taste, mai) (VES | WO) Dizziness, vertigo YES |(Noy Use of assistive device (glasses, hearing aida) VES KX) | Gag reflex intact (WEST NO | Cardiovascular Additional Detail = Cardiac monitor WES] NO” | Rhythm interpretation: Wevinal Sinus Raythim Pulses (radial, pedal) palpable, equal, strong |@ES)| NO R pedal ay = Wdial #7. ‘Normal heart tone ($1, 52), regular NO Caplar Feil (< seconds all earemties) —|WES)] NOExtremity temperature warm to touch, bilateral upper and lower extremities Edema presence Specify location and degree 0-4 scale Ree te Pacemaker ‘Specify type (temporary, permanent) CVP monitoring ‘Transducer zeroed, pressure bag checked for fluid/pressure level, no air present. Pulmonary Artery catheter (Swan) a "Tansee toed, pressure bag checked Tor | fluid/pressure level, no air present Respiratory Additional Detail Respiration pattern regular without effort NO - Use of accessory muscles ©) Productive cough © ‘Sputum production GO) _| Description of sputum: Nonproductive cough oO ‘Lungs clear to auscultation all fields NO Use of oxygen Ao] Sop chone and hen ‘Oxygen humidification NO Chest tube WD | Location: Is there an air leak? IFYES, Intermittent or continuous? Water seal: Suction: Ordered sxn level:[ Smoker [= = Specify current or past hie ‘Additional comments for abnormal assessment findings: Mechanical Ventilation 'spatient on ventilator? | YES io) Ventilator mode Foz PEEP Rate Tidal volume Type of airway tube Indication Noninvasive Ventilation [patie too | ventilation (Bipap or CPAP)? Foz jee ee EPABF minH20 Rate (For Bipap ONLY) |PAP-Inspiratory positive airway pressure; EPAP-Expiratory Positive Airway Pressure‘* For mechanical ventilation: ©. Was the patient sedated on a continuous IV infusion (s)? List ALL infusions ordered for sedation. : Was the patient rest paralyzing medications? ed either with physical restraints or chemically with (© Ifthe patient was physically restrained, what additional assessments were completed {including frequency) to ensure that the patient was safe? ‘© What additional interventions were taken to help prevent the development of VAP (ventilator-associated pneumonia)? ‘© For AlL patients: © Was a bag-valve mask (Ambu-bag) present in the room and easily accessible? Gastrointestinal ‘Abdomen soft, nontender all quadrants [YES)] NO Bowel sounds present x4 quadrants [S| NO | Specify: active, hypoactive, absent achive all 4 quadvants Nausea Ys [00 Vomiting YES | @E5 | Description: NG tube (FES) NO | Describe drainage color, amount, Ap nav consistency, location of tube: ie Z Post=ovlun c'» fzeding | Problems swallowing YES [NOD 2: Problems chewing [ves | RS | Dentures ‘YES | WO Needs asistance with feeding — YES | WO | ® Enteral WO | Type of feeding tuber CAT. ater Gluevng 1S “ us os Gora litkevm Rate: (9) wl [hic YOEO eal 105 Peder‘Stool Describe amount, color, consistency: M24. -byown, SFE Ostomy YES |@O)_| Describe type of ostomy, stoma she and output: ‘Additional I tubes YES (ROD | Spec Additional comments for abnormal assessment findings: Urinary Continent, voiding without difficulty (GED| NO Incontinent YES |(NO) | interventions: Foley catheter, patent, down drain, secured toleg | YES © Urine clear, light yellow to amber, no odor (S)[No YES | (10) | Specify ‘Additional GU tubes Additional comments for abnormal assessment findings: For ALL patients with indwelling Foley catheters: * What additional assessments and/or interventions were completed to help in the Prevention of the development of a CAUTI (Catheter associated urinary tract infe ny? Musculoskeletal Normal muscle tone without weakness a) NO. Wodevale ‘Able to transfer independently ie OT Unable ty assess (ued nsf iEing \D Purposeful movement, all extremities (YES NO ‘Normal skeletal alignment/structure (@es)] NO ‘Altered galt (@ED|NO | Specify Awputation Orthopedic device (cast, splint, brace) YES ]@0) | Specify Fall risk. ‘YES)} NO _ | Specify rationale Skin R abdaminalqroin L -meishne [ Skin dry, intact, color within patient norm | YES (NO 1G ankle Malothic Uai- lateral tniqhs Donoy siteS- we ‘Mucous membranes moist No Evidence of skin breakdown YES [NO | Speqfy location: Feanuss sa@al Rashes or bruising YES (NOS) | Specify location: ‘Sutures, staples, steri-strips YES {NO | Specify: 4 Wound drainage Yes |NO | Describe drainage: Avnpotation Site wound Vac ‘Wound drain [CED | NO | Speci: CAVE Tora Braden ScoreFor ALL patients with impaired mobility: ‘* Was physical therapy/occupational therapy ordered on the patient? ye < 5 Horesent, describe the exercses/activy performed? dtd. weig Mts Did the patient tolerate the activity? Yes 's there a decline or improvement in the patient’s ability since beginning therapy? Sele Pr vemains FOR ALL patients: * Based upon your assessment findings, is your patient at risk for developing skin breakdown? yes ‘* What additional preventative measures have been implemented or would you anticipate Using to preserve the patient’ skin integrity? ii Tp, mol ste fom wound - Skin folds Pain Pain Score x ‘out of 10 (10 being severe pain, 1 minimal pain) Characteristics ‘owning Shavp Onset avadwal Locate Upper Weg Wile Duration Exacerbation | WON CAV ‘ivan _galpation Radiation Relief \mUTeZAHON | Wudicarion Associated symptoms Buel Pa aoa Standards of Care NO | YES | INTERVENTIONS ORDERED IFOF BI? BVT proshvans V | nora parin (LoveNox) 4omq "rl GI Stress ulcer prevention v Ventilator associated pneumonia (vaP) i A