University Graduates

‫محافظة الخليل‬/ ‫رابطة الجامعين‬

Union
Palestine Polytechnic
‫جامعة بوليتكنك فلسطين‬
University
College of Nursing ‫كلية التمريض‬

Fundamental clinical worksheet

St name: Mahmood munther asafrah

Instructor name : karim sbaih

Client initials: RA.R.AW

Marital status: married
Occupation: National security officer
Unit : Rehabilitation department
Bed :5
Age : 63
Weight: 114
:Current medical diagnosis
.cervical vertebrae fraction due to falling
:Chief complaint
.Lack of feeling in the lower half of his body )1
.Insensitivity to output and urination )2
.Partial damage to the right and left hand )3
:Brief medical and surgical history
. surgery in right fibers)1
heart retina )2

: Diagnostic procedures and interpretation

Diagnostic test Rational Interpretation
MRI visualization of the fracture in three
spine vertebrae
gastroscopy He has dark colored positive
stools

:Pathophysiology of disease
C1 fractures typically result from axial loading. C2 fractures typically
occur due to a combination of compression, hyperflexion, and
hyperextension. Subaxial cervical spine fracture is commonly seen with
.high impact accidents such as motor vehicle accidents

: Vital sings
T: 36.2 )1
Bp: 115/65 )2
Hr: 84 )3
SPO2: 95% )4

Allergy :NKDA

Diet : sugar-free diet

.Activity order : does not walk

.Limitation : Fracture of three cervical vertebrae

: Lab test

Test name Pt. results Normal range Interpretation

CRP 134.0 0-5 Abnormal
indicator of
inflammation
Bun 16.9 8-23 Normal
Sodium 138 135-145 Normal

Intravenous solutions:(NACL)(125cc/h)

Medications : Patient
Name Time Dose Route Rational for Nursing
administration implication
Aspirin 24 100 Po Analgesic )1
heat reducer )2
Anticoagulants )3
PEPTICUM 24 20Mg Po .stomach ulcers
CAPS
*15
CLEXANE 24 60mg Iv Treatment of
blood clots that
 occur in the leg
.veins
PLAVIX 24 75mg Po To prevent
blood clots in
hardened blood
.vessels
lipidix 24 40mg Po Hyperlipidemia,
especially high
..cholesterol

:Nursing Care plan

.Bed sores)1
.diarrhea -2
.dyspnea -3
.blood stasis-4

Assessment Nursing Plan Intervention Rational Evaluation

diagnosis and
outcome
Bedsores Risk for Prevent Change pt Prevent Met
pressure pressure position Bed
ulcer ulcer Q2hrs .sores
R /T
immobilit
y
Diarrhea Risk for Prevent Provide I.V Prevent Met
dehydrati possible fluid dehydra
on R/T dehydra tion
diarrhea tion
dyspnea Dyspnea To O2 therpy To Met
R/T prevent Semi setting prevent
Abdomen S.o.B posstion S.O.B
distention
Blood stasis Risk for Prevent Rest,O2 To Met
venous Blood , therapy prevent
thromboe clotting Elastic socks Pulmon
mbolism ary
R/T
Blood embolis
stasis m