Assignment: Week 4 Section 5 (3/4)

M, D Health Care Provider: R S

Sex: F Weight: Code Status: 01 Isolation: 00 Food Allergies: 00 Diet: 01 Hospital Floor:

Age: 52 Y Height: Alerts: 00 Drug Allergies: 04 Env. Allergies: 00 BMI: Medical-Surgical

Student: Rebecca Sopelak Assignment: Week 4 Section 5 (3/4) Submitted: 03/05/2015 17:54

Clinical Assignment Grading

Assignment Objectives
No assignment objectives entered.

Clinical Set-up Details

First Day of Clinical: 03/04/2015 Primary Diagnosis: Guillain-Barré
syndrome

Provider Name: S, R Secondary Diagnosis: Diabetes mellitus

Student Details: Patient Details:

First Initial: R Identifier 1: D

Last Name: Sopelak Identifier 2: M
Credentials: SN Gender: F
Age: 52 Years

Pre-Clinical Manager

Patient Info Identifier: M, D Gender: F Age: 52 Y Nurse Initials: R Sopelak, SN

Diagnosis (2)

Primary Diagnosis: Guillain-Barré syndrome

Patho-Physiology:
Admission date: 02/26/15
Autoimmune disorder in which the body's immune system attacks its nerves resulting in weakness and tingling in the
extremities, with eventual paralysis of the whole body.
Symptoms: weakness in her legs, pain radiating from her arm, down the back, into the legs
Therapeutic Regimen:
--
Current Health Problems and Related Functional Changes:
HPI: Several month history of progressive ascending lower extremity weakness after upper respiratory illness last
winter. Non-insulin dependent Type 2 diabetic with hypertension, hyperlipidemia, chronic pain syndrome, and Vitamin D
deficiency, who also has peripheral neuropathy. There is ongoing evidence of objective demyelination confirmed by
EMG nerve study. She has been trying to work with therapy at home, but this became impossible to manage and given
that there is the outside possibility that this could be a complex inflammatory demyelinating polyneuropathy, it is
reasonable to admit her for IV immunoglobulin therapy on 5-day protocol. Great

Secondary Diabetes mellitus

Diagnosis:
Patho-Physiology:
Non-insulin dependent Type 2
Patho: insulin resistance on the cells leading to hyper-secretion of insulin from the pancreas, but over time the pancreas
stops secreting insulin for the body to use.
Therapeutic Regimen:
--
Current Health Problems and Related Functional Changes:
-Peripheral neuropathy
-Guillan-Barré syndrome Good

Medications (9)

Medication:Insulin Lispro - (Humalog) Classification:

Insulin
Route: Subcutaneous Dose: Sliding scale
Frequency:TID15AC Date 01/01/1900
Ordered:
Comments and Additional Medication Info: Therapeutic Effect:
Used for extra coverage in case blood sugars rub high --
due to illness
Action: Contraindications:
Stimulates peripheral glucose uptake --
Side Effects or Adverse Reactions: Life Threatening Considerations:
-- --
Recommended Dose Ranges: Nursing Interventions:
-- Monitor blood glucose Educate on signs and symptoms
of hypoglycemia Don't administer if not meeting sliding
scale parameters Good

Medication:Metformin Tablet - (Glucophage) Classification:

Antidiabetic: Biguanide
Route: Oral Dose: 750 mg
Frequency:Daily Date 01/01/1900
Ordered:
Comments and Additional Medication Info: Therapeutic Effect:
Give to control hypoglycemia all day --
Action: Contraindications:
Decreases hepatic glucose production and intestinal --
glucose absorption Increases insulin sensitivity
Side Effects or Adverse Reactions: Life Threatening Considerations:
-- Monitor for signs of GI upset Give with food (at
breakfast) Monitor blood glucose Monitor for signs and
symptoms of hypoglycemia
Recommended Dose Ranges: Nursing Interventions: Good
-- --

Medication:Docusate Sodium Capsule - (Colace) Classification:

Gastrointestinal agent: other
Route: Oral Dose: 100 mg
Frequency:BID Date 01/01/1900
Ordered:
Comments and Additional Medication Info: Therapeutic Effect:
Give to promote bowel elimination --
Action: Contraindications:
Facilitates reabsorption of water into the stool to soften it --
Side Effects or Adverse Reactions: Life Threatening Considerations:
-- --
Recommended Dose Ranges: Nursing Interventions:
-- Monitor for abdominal discomfort Document input/output
Good

Medication:Amitriptyline Tablet - (Elavil) Classification:

Antidepressant: tricyclic
Route: Oral Dose: 10 mg
Frequency:TID Date 01/01/1900
Ordered:
Comments and Additional Medication Info: Therapeutic Effect:
Give for depression --

Action: Contraindications:
Block the reuptake of serotonin and norepinephrine --
Side Effects or Adverse Reactions: Life Threatening Considerations:
-- --
Recommended Dose Ranges: Nursing Interventions:
-- Assess neurological state of being Monitor for
symptoms of increased depression, suicidal ideation
Good

Medication:Estradiol Tablet - (Estrace, Gynodiol) Classification:

Hormonal agent,
stimulant/replacement/modifying (sex
hormone/modifier): estrogen
Route: Oral Dose: 1 mg
Frequency:Daily Date 01/01/1900
Ordered:
Comments and Additional Medication Info: Therapeutic Effect:
Treatment for postmenopausal symptoms --
Action: Contraindications:
Binds to estrogen receptors Develops and maintains --
female sex characteristics and reproductive systems
Side Effects or Adverse Reactions: Life Threatening Considerations:
-- --
Recommended Dose Ranges: Nursing Interventions:
-- Monitor for alterations with diabetes Watch for signs of
thromboembolism, MI, stroke Good

Medication:GlipiZIDE Tablet - (Glucotrol) Classification:

Antidiabetic: Sulfonylureas
Route: Oral Dose: 5 mg
Frequency:BID Date 01/01/1900
Ordered:
Comments and Additional Medication Info: Therapeutic Effect:
Prevention if hypoglycemia, day long coverage --
Action: Contraindications:
Stimulates pancreatic islet beta cell insulin release --
Side Effects or Adverse Reactions: Life Threatening Considerations:
-- --
Recommended Dose Ranges: Nursing Interventions:
-- Monitor for signs of hyperglycemia from overstimulation
of islet beta cells Monitor blood glucose Good

Medication:Meloxicam Tablet - (Mobic) Classification:

Analgesic: non-opioid
Route: Oral Dose: 15 mg
Frequency:Daily Date 01/01/1900
Ordered:
Comments and Additional Medication Info: Therapeutic Effect:
For her chronic pain management --
Action: Contraindications:
Inhibits COX, reduces prostaglandin and thromboxane --
synthesis

Side Effects or Adverse Reactions: Life Threatening Considerations:

-- --
Recommended Dose Ranges: Nursing Interventions:
-- Monitor for GI bleeds Assess pain Take with food to
prevent GI upset Good

Medication:Gabapentin Tablet - (Neurontin) Classification:

Anticonvulsant: other
Route: Oral Dose: 900 mg
Frequency:TID Date 01/01/1900
Ordered:
Comments and Additional Medication Info: Therapeutic Effect:
Neuropathic pain due to diabetes and Guillan-Barre --
syndrome

Action: Contraindications:
Blocks voltage-dependent calcium channels Modulates --
excitatory neurotransmitter release
Side Effects or Adverse Reactions: Life Threatening Considerations:
-- --

Recommended Dose Ranges: Nursing Interventions:

-- Monitor for suicide ideation because it can cause
suicidal thoughts in depressed patients Monitor WBC
count Don't abruptly withdraw Good

Medication:Vitamin D3 (Cholecalciferol) Tablet Classification:

Vitamin
Route: Oral Dose: 2000 units
Frequency:Daily Date 01/01/1900
Ordered:
Comments and Additional Medication Info: Therapeutic Effect:
Supplement for vitamin D deficiency --
Action: Contraindications:
Adds extra vitamin c into the diet Aids in the absorption --
of calcium

Side Effects or Adverse Reactions: Life Threatening Considerations:

-- --
Recommended Dose Ranges: Nursing Interventions:
-- Give with calcium for optimal absorption Good
Laboratory Tests (2)

Laboratory Complete Blood Cell Count (CBC) Date of 02/27/2015

Test: Test:
Definition and Description:
--
Significance of the Test Being Ordered for this Patient:
--
CBC: RBC
Test 4.35
Result: Result
Level:
Within Normal Limits
Result Significance:
--
CBC: Hgb
Test 14.6
Result: Result
Level:
Within Normal Limits
Result Significance:
--
CBC: Hct
Test 41.5
Result: Result
Level:
Within Normal Limits
Result Significance:
--
CBC (RBC Indices): MCV
Test 95.5
Result: Result
Level:
Within Normal Limits
Result Significance:
--
CBC (RBC Indices): MCH
Test 33.6
Result: Result
Level:
Within Normal Limits
Result Significance:
--
CBC (RBC Indices): MCHC
Test 35.2
Result: Result
Level:
Within Normal Limits
Result Significance:
--
CBC (RBC Indices): RDW
Test 13.2
Result: Result
Level:
Within Normal Limits
Result Significance:
--
CBC: WBC
Test 7.8
Result: Result
Level:
Within Normal Limits
Result Significance:
--
CBC: Blood Smear
Test --
Result: Result
Level:

Result Significance:
Not done
CBC: Platelet Count
Test 245
Result: Result
Level:
Within Normal Limits
Result Significance:
--
CBC: MPV
Test 7.8
Result: Result
Level:
Within Normal Limits
Result Significance:
--

Laboratory Basic Metabolic Panel Date of 03/01/2015

Test: Test:
Definition and Description:
--
Significance of the Test Being Ordered for this Patient:
--
Basic Metabolic Panel: Blood Urea Nitrogen (BUN)
Test 28
Result: Result
Level:
Within Normal Limits
Result Significance:
--
Basic Metabolic Panel: Calcium
Test 8.6
Result: Result
Level:
Within Normal Limits
Result Significance:
--
Basic Metabolic Panel: Chloride
Test 107
Result: Result
Level:
Within Normal Limits

Result Significance:
--
Basic Metabolic Panel: CO2
Test 26
Result: Result
Level:
Within Normal Limits
Result Significance:
--
Basic Metabolic Panel: Creatinine
Test 0.60
Result: Result
Level:
Within Normal Limits

Result Significance:
--
Basic Metabolic Panel: Glucose
Test 92
Result: Result
Level:
Within Normal Limits
Result Significance:
--
Basic Metabolic Panel: Potassium
Test 4.0
Result: Result
Level:
Within Normal Limits
Result Significance:
--
Basic Metabolic Panel: Sodium
Test 137
Result: Result
Level:
Within Normal Limits
Result Significance:
 --

Diagnostic Tests (1)

Diagnostic Electrocardiogram: 12-Lead Date of 03/04/2015

Test: Test:
Definition and Description of the Test:
Complaint of chest pain and dyspnea
Significance of the Test Being Ordered for this Patient:
--
Significant Findings and Results:
EKG came back normal, BP medication administered and pain subsided Good

Clinical Grading:

Clinical
Grade:

Remarks: Good write up of pathophysiology, medications and labs.

Care Plan Details

Care Plan

Priority
1 Medical Diagnosis: Guillain-Barré syndrome Created By: R Sopelak, SN 03/05/2015 | 16:54
Nursing Diagnosis: Impaired physical mobility Modified By: R Sopelak, SN 03/05/2015 | 17:04

Status: Active Type:

Actual

Related To
Activity intolerance
Anxiety
Decreased muscle strength
Neuromuscular impairment
Pain

Evidenced By
Jerky movements
Postural instability
Slowed movement Good

Expected Outcome Measurement/Time Frame Comments

Patient will meet by moving from a two-assist to one ass She got up with one-assist when she go
mutually defined goals ist ambulation by the time of discharge t up to shower an hour before her disch
of increased physical arge
activity and
ambulation.
Patient will verbalize by being able to get up with one assist, She got up from the bed to the shower, f
less fear of falling and 3 times, over the course of the shift. M rom the shower to the chair, and from th
pain with physical ake measurable-how does this measu e chair back to the bed with one assis
activity. re fear of falling or pain? t. Those were 3 times that she moved a

Interventions
Assessing skin condition
at every visit
Consulting with physical
therapist
Increasing independence
in activities of daily living
(ADLs)
Obtaining any assistive
devices needed for activity
Referring the patient to
home health aide services
to support the patient and
family
Priority
2 Medical Diagnosis: Diabetes mellitus
Nursing Diagnosis: Peripheral neurovascular
dysfunction, Risk for
Status: Active
Related To
Immobilization
ADDED-neurovascular disease
Evidenced By
Abnormal movement/inability to move extremity
Abnormal sensation of an extremity if someone is "at risk" there will not be an AEB statement since it has not
occurred.
Expected Outcome
Patient will explain signs of
neurovascular compromise
and ways to prevent venous
stasis.
Patient will maintain
circulation, sensation, and
movement of an extremity
Rationale
because she has lack of i
mmobility, pressure ulcers
are more likely to form
to develop modifications to
increase independence de
spite her restrictive syndro
me
so that she doesn't start to
obtain functional decrease
s and continue to care for h
erself as long as she can
because Guillan-Barre syn
drome causes progressive
extremity weakness, which
is manifested in her legs.
because the disease will p
rogress, so you need to giv
e them the option of what t
here is that can help them
Created By: R Sopelak, SN 03/05/2015 | 16:38
Modified By: R Sopelak, SN 03/05/2015 | 17:18
Type:
Actual
Measurement/Time Frame
by stating 3 ways to prevent v
enous status before discharg
e Good
by changing to 3 different po
sitions during the shift Good
nd each was assisted by just her husba
nd.
Comments
Her skin was assessed with each transfer, no si
gns of pressure ulcer formation.
She didn't want to talk to anyone about her imm
obilities, so PT was not consulted
She got up and took a shower on her own. She
did have to sit in a chair and needed help to get
there, but she did shower independently.
With her weakness, she does need a wheelcha
ir to help her move from place to place. From h
er bed to the shower, she needed to be wheele
d in using the wheelchair because the distance
was too far for her to walk.
She was discharged to skilled care. Her and h
er husband were given information of other opti
ons in case she does want to go home.
Good interventions and evaluation.
Comments
She knows that elevating her feet, ambulati
ng, and wearing TED hose can help her pre
vent venous stasis.
She got up and moved to the shower and c
hair. She also went from laying on her side
to a sitting position in the bed. This was 4
 within normal limits.
Interventions
Getting the patient out of bed
as early as possible and
ambulating frequently
Monitoring the patient for
symptoms of deep vein
thrombosis (DVT)
Performing a neurovascular
assessment
Referring the patient to a
rehabilitation facility as
needed
Teaching the patient and
family to recognize signs of
neurovascular dysfunction
and stressing the need to
report them immediately
Care Plan Grading:
Care Plan
Grade:
Remarks: Remember that "at risk" diagnosis will not have an AEB statement. Work on making goals measurable. Good
interventions and evaluation.
Charting Details
Admission History
Admission Data
Informant/Historian
Information received from:
Arrived By
different position changes that occurred dur
ing the shift.
Rationale Comments
to prevent pressure ulc We got her out of bed, but it was into a wheelchai
ers r. She couldn't stand for more than 5 minutes and
went right back to bed. This was slightly affective
because we did move her to relieve pressure poi
nts, but it didn't get as far as ambulation.
because of her lack of Her legs were assessed for signs of DVT. Homa
movement and inabilit n's sign was negative, her legs were symmetrical
y to bear weight for ext in size. No warmth or redness present over either
ended periods of time leg.
to assess for progress The neuropathy was lessening from the day befor
ion of neuropathy e. Her activity tolerance increased and her ability
to ambulate with less help than the day before. W
hen I got there she was a 2-assist and by the mid
dle of the shift she was a 1-assist. Neurotin was
given to the lessen the signs and symptoms of ne
uropathy.
to help her try to regai The patient was referred to skilled nursing to help
n strength that is progr her with further treatment.
essively lost from the n
europathy and Guillai
n-Barre syndrome
because increased ne She was taught the further signs and symptoms a
urovascular dysfunctio nd what to expect for the disease. It was emphas
n can be a sign of pro ized that the disease is progressive so it will occu
gression of Guillain-B r over time.
arre syndrome
Good interventions and evaluation
Created By: R Sopelak, SN
03/04/2015 | 10:13
Modified By: R Sopelak, SN 03/04/2015 |
10:51
Self
 Wheelchair
This Admission

Admitted from: Admitting office

Health History

Other Health History

Hyperlipidemia, Chronic pain, Vitamin D deficiency, Guillan-

Barre syndrome
Endocrine Disorders

Is compliant with diabetic regimen

Diabetes: Controls with oral medication
Cardiovascular Problems

Hypertension
Mental Health

Mood disorders

Allergy Information

Do you have any known allergies to Yes

drugs, food, or environmental items?
Allergy Info

Type Allergen Reactions Severity Informant Confidence Entered By Entered

Level Day/Time
Medicati Doxycycli Unknown Unknown Self Very R 03/04/20
on ne Reliable Sopelak, 15 10:29
Hyclate SN
Capsule
-
(Vibramy
cin)
Medicati Erythrom Unknown Unknown Self Very R 03/04/20
on ycin Reliable Sopelak, 15 10:29
(Base) SN
Tablet
Medicati Tetracycl Unknown Unknown Self Very R 03/04/20
on ine Reliable Sopelak, 15 10:30
Capsule SN
- (Emtet-
500)
Medicati Vancomy Unknown Unknown Self Very R 03/04/20
on cin Reliable Sopelak, 15 10:30
Capsule SN
-
(Vancoci
n
 Pulvule)

Home Medication Information

Do you take any medications, herbal Yes

products, vitamins, or supplements at
home?
Information Received From: Self
Self
Prescription Medications
Name Dose/Form Route Frequency Last Indication Entered By Entered
Dose Day/Time
Hydrochl 25 Oral Daily R 03/04/2015
orothiazi MG/Tabl Sopelak, 10:13
de et SN
Tablet -
(Ezide)
Losartan 100 Oral Daily R 03/04/2015
Tablet - MG/Tabl Sopelak, 10:14
(Cozaar) et SN
Furosem 40 Oral Dail R 03/04/2015
ide MG/Tabl Sopelak, 10:15
Tablet - et SN
(Lasix)
Citalopra 40 Oral Daily R 03/04/2015
m MG/Tabl Sopelak, 10:16
Tablet - et SN
(Celexa)
Amlodipi 10 Oral Daily R 03/04/2015
ne MG/Tab Sopelak, 10:17
Tablet - SN
(Norvasc
)
Meloxica 10 Oral Daily R 03/04/2015
m MG/Tabl Sopelak, 10:18
Tablet - et SN
(Mobic)
Metformi 500 Oral Dail R 03/04/2015
n Tablet - MG/Tabl Sopelak, 10:19
(Glucoph et SN
age)
Ipratropiu /Nasal Nasal Daily R 03/04/2015
m Nasal Sopelak, 10:21
Spray - SN
(Atrovent
Nasal
Spray)
GlipiZID 5 Oral BID R 03/04/2015
E MG/Tabl Sopelak, 10:22
Extende et ER SN
 d
Release
Tablet -
(Glucotro
l XL)
Acetami 10MG/32 Oral Q6H R 03/04/2015
nophen/ 5MG 1 PRN Sopelak, 10:23
Oxycodo TAB/Tabl SN
ne et
10/325
Tablet -
(Percoce
t 10/325,
Endocet
10/325)
Elavil 10MG/32 Oral TID R 03/04/2015
5MG 1 Sopelak, 10:24
TAB/Tabl SN
et
Gabapen 10MG/32 Oral TID R 03/04/2015
tin 5MG 1 Sopelak, 10:25
Tablet - TAB/Tabl SN
(Neuronti et
n)
Vitamin 10MG/32 Oral Daily R 03/04/2015
D3 5MG 1 Sopelak, 10:26
(Choleca TAB/Tabl SN
lciferol) et
Tablet

Drug Screen

Street/Recreational/Excessive Prescription Drug Use

Has never used street/recreational/excessive prescription

drugs

Smoking Screen

Do you live with a smoker? No

Smoker Status

I have never used tobacco.

Alcohol Screen

Do you drink alcohol? No

Role/Relationship

Marital or Partner Status

 Married
Family Processes

Participates as decision-maker in family

Caregiver Role

Has no caregiver responsibility

Role Performance

Needs strong family/partner to help successfully meet role

requirements
Social Interactions

Somewhat outgoing when encouraged by others

Culture/Spirituality

Are there religious, cultural, or ethnic No

concerns we should consider while
you are in the hospital?
Do you want clergy to visit you while No
you are in the hospital?

Discharge Planning Created By: R Sopelak, SN

03/05/2015 | 16:21
Modified By: R Sopelak, SN 03/05/2015 |
17:52

Discharge Planning

Motivational level

Asks questions
Tentative needs before discharge

Treatment plan
Referral, support services
Planning for Returning Home

To whom should discharge care Self

instructions be given?
Name:
Who will care for you after discharge?
What is your anticipated discharge
destination?
What services have been established
for after discharge?
What is your current living arrangement?
What was your care status before this
admission?
Augusta Health Skilled Nursing
Other (Skilled Nurse)
Skilled nursing Good
Other (Skilled Nursing)
Lives with family/relatives
Partial assistance needed

Special Charts - Miscellaneous Nursing Notes

Miscellaneous Nursing Notes Created By: R Sopelak,

SN 03/05/2015 | 17:50
 Article: The Epidemiology of Guillain-Barre Syndrome
Author: Milton Atler, MD, PhD
Link:
http://onlinelibrary.wiley.com/doi/10.1002/ana.410270704/abstract;jsessionid=BDE24A4956D631A46E31FBBD221A0326.f01t01?
systemMessage=Wiley Online Library will be disrupted on 7th March from 10:00-13:00 GMT (05:00-08:00 EST)
for essential maintenance. Apologies for the inconvenience.

Article Discussion:
My patient today was hospitalized for Guillain-Barre syndrome. I had no clue what that was, so I looked into
it. When I found out it was a neuropathy that can progressively paralyze a person, I was intrigued. I was intrigued
because in her past medical history, I found that she was a Type 2, non-insulin dependent, diabetic. I was curious
as to if there was a link between her diabetes and Guillain-Barre syndrome. I found an article about a study done
on Guillain-Barre patients to try to determine the epidemiology of the disease. When Dr. Atler was trying to define
who was a fit subject for this study he was contemplating allowing diabetics into the study or not. He was
concerned because Guillain-Barre can cause neuropathy to occur quickly, over a few days, whereas diabetic
neuropathy is normally a slower process. However, he did find that neuropathies can occur quicker in diabetics
because they already are susceptible to the neuropathies. From his study, it seems that diabetes doesn't cause
the development of Guillain-Barre, but rather, can exacerbate the symptoms of Guillain-Barre because of their
increased susceptibility to neuropathy. Good article and write up.

Today's Summary:
Today, both my patients were discharged. Because of this I got to discontinue 3 IV's. My nurse was awesome and
showed me the whole discharge process. I got to help move one of them who was being discharged downstairs to
skilled nursing and helped the CNA get the other one into her son's car to go home. After that, I pretty much just
helped with whatever my nurse needed. Good

IVs
1. Right Dorsal Cephalic (Forearm)

Created By: R Sopelak, SN 03/04/2015 | 10:35

IV Status: Discontinued Type of IV Peripheral

Access:

Catheter Type: Over-the-needle Catheter Size: 24-gauge

Number of 1 Skin Insertion site clean and

Insertion Assessment: dry
Attempts: No redness or swelling
noted

Dressing Care: Dressing clean and dry Patency: Intermittent line flushed
Transparent dressing per hospital protocol
placed over IV site and
Patient No complaints at this
dated
Response: time
Tolerated procedure well

2. Left Dorsal Metacarpal

Created By: R Sopelak, SN 03/04/2015 | 10:36

 IV Status: Active Type of IV Peripheral
Access:

Catheter Type: Over-the-needle Catheter Size: 24-gauge

Number of 1 Skin Insertion site clean and

Insertion Assessment: dry
Attempts: No redness or swelling
noted

Dressing Care: Dressing clean and dry Patency: Intermittent line flushed
Transparent dressing per hospital protocol
placed over IV site and
Patient No complaints at this
dated
Response: time

Assessed By: R Sopelak, SN 03/05/2015 | 17:52

IV Status: Discontinued Condition of Intact

catheter:

Site appearance: No redness or swelling Type of IV Peripheral

noted Access:

General Orders

Code Status Created By: R Sopelak, SN 03/04/2015 | 00:00

Status: Active
Intervention: Full code

Nutrition

Sodium-Controlled Diet Created By: R Sopelak, SN 03/04/2015 | 00:00

Status: Active
Order Start Date: 03/04/2015 00:00
Diet Type: Sodium-Controlled Diet
Consistency: Normal

Patient Card

Order Description Category Status Last Discontinued Entry By

Date/Time Performed By

03/04/2015 Full code Code Status Active -- ---- R

| 00:00 Sopelak,
SN
03/04/2015
00:00
03/04/2015 Normal Sodium- Active -- ---- R
| 00:00 Controlled Sopelak,
Diet SN
03/04/2015
00:00
03/05/2015 Guillain-Barré Care Plan Active -- ---- R
 | 16:38 syndrome-Impaired Sopelak,
physical mobility SN
03/05/2015
16:38
03/05/2015 Diabetes mellitus- Care Plan Active -- ---- R
| 16:54 Peripheral Sopelak,
neurovascular SN
dysfunction, Risk for 03/05/2015
16:54

Charting Grading:

Charting
Grade:

Remarks: Great article and write up.

Competencies
No competencies entered.

Remarks: 5

Overall Grading:

Care Plan Pre-Clinical Manager Grade: Charting

Grade: Grade:

Overall Grade: 98%

Remarks: Great Job. See Rubric I e-mailed.

Copyright © 2015 Elsevier Inc. All Rights Reserved.