Clinical Worksheet

Date: _06/19/2020_________ Student Name: ___Jackie Griffis_________ Assigned vSim: _Christopher Parrish
Initials: CP Diagnosis: Cystic HCP: Dr. Who Isolation: None IV Type: Critical Labs: Other Services:
Fibrosis Location: N/A Fecal lipid, liver
Age: 18 enzyme, serum
Fall Risk: No electrolyte, albumin,
M/F: M Consults: Fluid/Rate: N/A Consults Needed:
arterial blood gas, fecal
Length of Stay: D1 Nutritional consultant
Code Status: Transfer: None elastase-1, Creatinine,
uric acid
Allergies: None
Why is your patient in the hospital (Answer in your own words and include the History of present Illness): Admitted to the ED at 1900 06/19/2020 after feeling
fatigued, loss of appetite and loss of 6 kg.

Health History/Comorbidities (that relate to this hospitalization): History of cystic fibrosis. Recently moved into dorm rooms for college and has since lost
appetite, resulting in a 6 kg weight loss. Pt often feels fatigued.

Shift Goals/ Patient Education Needs:

1. Education on diagnostics, intake and output, BMI, Diet, feeding tubes, and aspiration

2. Get pt up and walking as much as possible.

3. Give Pancrelipase 5 capsules PO before tube feedings, and 3 capsules before snacks. Multivitamin 2 tabs PO each morning, Fluid Nutrition: 1.5Kcal/mL in NG
tube, 720 Kcal over 8 hours at night. Keep bed in low fowlers during feeding and one hour after feedings are finished.

4. Track intake and output

Path to Discharge: Education of the PT, monitor vitals and temperature, monitor NG tube, Continue Pancrelipase before feedings and multivitamin, ambulate as
much as possible, bed in low fowlers during NG feedings and one hour post-feeding. Physical therapy for joint maintenance. Nutritionist consultation. Monitor for
anxiety, depression.
Path to Death or Injury: Pneumonia, malnutrition, bowel obstruction, shock

Clinical Worksheet (Continue to next page)

Alerts: Management of Care: What needs to be done for this Patient Today?
What are you on alert for with this patient? (Signs & Symptoms)
1. Vitals/auscultation
1.Weight
2. Educate patient and ambulation
loss
3. Assess ng tube
2. 4. Ambulation

Fatigue 5. Vitamins, Pancrelipase before meals/snacks, and Liquid nutrition feedings.

3. Low O2Sat or slow respiration (*12) 6. Monitor intake, output and bowel movements.

Priorities for Managing the Patient’s Care Today

1. Vitals/Temp/listen to lungs/bowels

2. Monitor NG tube placement. Vitamins, medication and liquid nutrition

What Assessments will focus on for this patient? (How will I
identify the above signs &Symptoms?) 3. PT Education and ambulation

1. Assess 4. Breathing exercises

NG tube

placemen *Set up nutritionist consultation, physical therapy for joint maintenance, and
possibly respiratory therapist
t

2.Monitor
What aspects of the patient care can be Delegated and who can do it?
input and Nutrition- nutritionist consultation, physical therapist-range of motion and
joint maintenance, respiratory therapist- breathing exercises.
output

and

appetite

3. Monitor for signs of pneumonia (fever, painful or labored breathing)

List Complications may occur related to dx, procedure, comorbidities:

1. Infection/pneumonia/aspiration

2. Malnutrition

3. Osteoporosis/arthritis

What nursing or medical interventions may prevent the above Alert or complications? PT
education on medication, diet, BMI, Tube feeding, aspiration, tube feedings while bed is no
lower than low fowlers position during and no less than one hour after feedings are finished,
breathing exercises, respiratory therapy, physical therapy, ambulation, and range of motion
exercises.