Clinical Worksheet

Date: _07/10/2020_________ Student Name: ___Jackie Griffis_________ Assigned vSim: _Mona Hernandez
Initials: MH Diagnosis:Pneumonia HCP: Dr. Who Isolation: None IV Type: Critical Labs: Other Services: Chest X-ray
of R Lobe Location: Right arm Hemoglobin, WBC, PH,
Age: 72 ABG, creatinine
Fall Risk: No
M/F: F Consults: Fluid/Rate: N/A Consults Needed:
Length of Stay: D2 Respiratory Respiratory therapist
Code Status: therapy Transfer: None

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 07/09/2020 with pain in right lower
chest and coughing. DX with Pneumonia in her right lower lung. PT is a smoker.

Health History/Comorbidities (that relate to this hospitalization): History of smoking cigarettes, dry cough, fever, malaise, and was dx with influenza 10 days prior
to admission.

Shift Goals/ Patient Education Needs:

1. Education on coughing, incentive spirometer use, pneumonia, and oxygen therapy

2. Assist in ambulation at least 3 times a day

3. Assess vitals every 4 hours, position to high fowlers, keep o2 sat at 95+ with supplemental o2

4. Encourage coughing and use of incentive spirometer, flush saline lock q8h & prn, medication as scheduled

Path to Discharge: Education of the PT, monitor vitals and temperature, ambulate at least 3 times a day, up to chair, use of incentive spirometer, encourage
coughing, deep breathing exercises 10 times/day, properly hydrate pt, continuation of scheduled meds, bed in high fowlers position and use of supplemental
oxygen
Path to Death or Injury: Pneumonia, infection, embolist, septic shock, respiratory failure

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 q4h
1.worsening
2. Educate patient
low o2 sat
3. Bed in high fowlers/up in chair
2.worsening 4. Ambulation at least 3 times a day

fever (over 5. Encourage use of incentive spirometer, coughing, deep breathing

101.5 6. Monitor temperature and 02 sat (keep at 95+) with supp o2

degrees Priorities for Managing the Patient’s Care Today

1. Vitals/Temp/listen to lungs
Fahrenheit)
2. Monitor sputum characteristics
3. RR less than 10/min 3. Bed in high fowlers/pt up in chair

4. Ambulate pt 3 times/daily

What Assessments will focus on for this patient? (How will I

*Set up consultation with respiratory therapist
identify the above signs & Symptoms?)

1. Vitals q4h
What aspects of the patient care can be Delegated and who can do it?
2. pulse
Breathing exercises- respiratory therapist, vitals-cna
oximeter

3. Ability to use incentive spirometer correctly

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

1. Worsening of infection/ septic shock

2. Lung abscess

3. Respiratory failure

What nursing or medical interventions may prevent the above Alert or complications? PT
education on medication, keep bed in high fowlers, ambulate pt 3 times daily, up in chair, use of
incentive spirometer, coughing, deep breathing exercises, medications as scheduled, keeping pt
properly hydrated, o2 sat at 95+ using supplemental o2 (nasal cannula)