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Clinical Worksheet and Care Plan

Ryan Brianne Jackson

School of Nursing, University of Louisville

NURS 346-01: Management of Care I

Krystal Cox

(November, 2022)
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University of Louisville School of Nursing

Clinical Worksheet
Student: Ryan Jackson Date of Care: 10/26/2022

Demographic Information Health History Care Prescriptions

Age: __63__ Gender: __F__
Preferred Pronouns: ______
Code Status: _Full code_______
Weight: _77.27___
Height:_5’6___ BMI: _25.9kg___
Chronic conditions & previous health problems:
AKI (Acute Kidney Injury)
GERD (gastroesophageal reflux disease)
Hypothyroid
PVD (peripheral vascular disease)
Schizoaffective disorder
Nutrition
Type of diet: ___normal ndd3/ special advanced (soft food)
_______________________________
 NPO
 Tube Feeds: Type ___________ Rate ________
 G tube  NG tube
 Aspiration risk  Thickened liquids: Type __________

Why patient believes they are
admitted:
Hypotension/ diarrhea
Reason for admission:
Hypotension, Pneumonia
Date of admission:
10/22/2022
Allergies:
Penicillin & Thorazine
Other notes:
Unexpected events/complications during stay: Activity:
1.  Independent  Assist  Dependent
none 2.  Ad lib  Up to chair  Ambulate  Bed Rest  Turn q___
3.  Assistance of _2__ (# of people)
Previous surgeries: [type/year]
Assistive devices:
N/A  Gait belt  mechanical lift  walker  cane
 Other : ___used sheets for assistance
_____________________________
Nursing Diagnoses (5, prioritized, with related factors Elimination:  Continent  Incontinent
and supporting evidence):  Voiding  Foley catheter  I & O
 Enema  Colostomy  Other: _____________
Skin/Wound Care:
 Intact skin  Moisture barrier: __________
 Dressing/drain
Location & Type______________________________
 Wound(s)
Location & Type______________________________
Discharge/Teaching Needs (3, prioritized – often this Pulmonary care:
is nutritional, self-care, new medications, wound
care, immunizations, etc.)  O2 ___ L/min via  N/C  mask
 Continuous O2 Sat
 Incentive Spirometer q ___ hrs.
 MDI inhaler (type: _______)
 Nebulizer (type: _______)
 Other: __room temp_________________
Glucometer:  ac & hs  other ____________
 sliding scale insulin
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Medications (scheduled & prn)

Name/Dose/ What are the Major Side Effects Nursing Implications Patient Education
Route drug actions, and
what effect does
the drug have on
the body?
Albuterol- Bronchodilators Tiredness, stuffy nose, It is a Beta 2 agonist, so you need Since there is vasodilation
ipratropium/3ml/ (opens up airway) sore throat, body to watch the HR, BP, and RR. occurring you want to make
nebulized aches, pain, urinary Make sure patient still has good I’s sure you dangle your feet
inhalation retention and O’s (check urine for before standing up (for
consistency and color to make sure orthostatic hypotension). Take
body is reacting well to the med) the exact prescribed dose. Let
healthcare provider know if
you have any difficulty
breathing while being on this
med!
Ceftriaxone/2g/ Antibiotic (helps Chest pain, chills, Watch out for seizures, and Do not stop your antibiotics
IV push injection to treat bacterial black tarry stools, diarrhea, monitor the GI system even if you start to feel better
infections) tiredness, swollen because the medication may affect or believe that they symptoms
glands, breath elimination and digestion. have gone away.
shortness
Apixaban Blood thinner Bruising, heavy Monitor for bleeding, the patients If you notice changes in the
(Eliquis)/5mg/ (anticoagulant) bleeding, headaches, are more sensitive to cuts or color of urine or stool notify
oral tab rash, pain in the injuries. If the skin is protruded a the healthcare provider. Be
muscles or joints patient could bleed out! careful to not cause impact on
(Budovich et al., your skin, or break your skin
2013) protective barrier- while being
on this medication you are
more applicable for drastic
bleeding when you cut
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yourself. Takes longer time

for cuts and wounds to heal!
Levothyroxine/ Treats Changes in appetite, Give this medication by itself, it Take this med one hour before
75mcg/ oral tab hypothyroidism weight fluctuations, could interact and interfere w/ eating, and take this med by
(under heat sensitivity, other drugs! IT’S NOT itself, don’t take with other
(Levothyroxine, functioning of the diarrhea, changes in COMPATIBILE WITH OTHER pills!
2021) thyroid) period (menstrual) MEDS!
cycles
Acetaminophen Pain reliever Rash, Hives, Bleeding Make sure this medication isn’t Only use when needed/ do not
(Tylenol)/ oral (black tarry stools), overly abused, overuse can lead to over use; Adults- do not
tab nausea, Tiredness GI problems such as GI bleed. ingest
4000mg in a day (24hrs) or
(Tucker, 2022) more than 1000mg at once.

Important diagnostic tests to monitor with rationale (Consider diagnosis, pre-existing conditions, medications,
complications, etc.—add or delete rows as needed)
Laboratory/Diagnostic Test Rationale
Potassium (3.0) low
RBC (2.34) low
Lymph % (46.8) high
Calcium (7.50 low
Hgb (7.1) low
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HEALTH ASSESSMENT FORM

Student Name: Ryan Jackson Date of Care _____10/26/2022

Reason for admission: __Hypotension, Diarrhea___________________________________

Vitals (Two sets: initial and at end of your shift):

Time Temp HR RR B/P (MAP) Position/ SpO₂ O₂ with delivery device
extremity
0700 98.1 98 18 129/83 Supine (lying 95
position)

1200 98.3 97 18 100/60 Supine (lying 94

position)

Braden Scale for Predicting Pressure Ulcer Risk Score

Sensory Perception Completely Limited (1) Very limited (2) Slightly limited (3) No impairment (4) 3
Moisture Constantly moist (1) Very moist (2) Occasionally moist (3) Rarely moist (4) 4
Activity Bedfast (1) Chairfast (2) Walks occasionally (3) Walks frequently (4) 2
Mobility Completely immobile (1) Very limited (2) Slightly limited (3) No limitations (4) 3
Nutrition Very poor (1) Probably inadequate (2) Adequate (3) Excellent (4) 2
Friction & Shear Problem (1) Potential problem (2) No apparent problem (3) 2
Total 16

Risk Category Score X Pressure Ulcer Prevention Intervention

At Risk 15-18 X Reposition Q 2 hours X Specialty bed
Moderate 13-14 Waffle boots Waffle cushion
High 10-12 Toileting program Absorbent pads X
Very High 9 or below Skin protectant cream Other
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Morse Fall Scale Risk Screening Score

History of falls Yes (25); No (0) 0
Secondary Diagnosis Yes (15); No (0) 0
Ambulatory Aid Furniture (30); Crutches/Cane/Walker (15); None/Bedrest/Nurse Assist (0) 0
IV Access/IV Therapy Yes (20); No (0) 20
Gait Impaired (20); Weak (10); Normal/Bedrest/Immobile (0) 10
Mental status Forgets Limitations (15); Oriented to Ability (0) 15
Total Score 45

Falls Risk Category Falls Prevention Interventions

Low= 0-24 Bed in low position X Sitter/family present Clutter-free environment X
Moderate= 25-44 Bed alarm Non-slid slippers/socks X Call light within reach X
High= 45 or higher X Bed rails up x ___ X Assistive device within reach X Other

Neuro:
LOC: Alert Confused Lethargic Obtunded Responds to painful stimuli
Non-responsive
Orientation: Person Place Time Situation
Pupils: Left: _____3______ mm Right: ______3_____ mm Reaction: _____w/ in defined limits_________________________
Strength: LUE: __4_______ RUE: ____4______ LLE: ___4_______ RLE: ____4_______
0=flaccid 1=muscle movement, but no effort against gravity 2=some effort against gravity 3=overcomes gravity, but weak 4=full strength
Sensation: LUE: ____4______ RUE: ______4_____ LLE: _____4______ RLE: ___4________

Cardiac:
Heart sounds: S1, S2 S3 Murmur Friction Rub Regular rhythm Irregular rhythm
Pulse: Right: Radial_____+1______ Pedal_____+1_____
Left: Radial___+1________ Pedal_____+1_____
UTA= Unable to Assess, D=Doppler, 0= Absent, 1+=Weak/ Thready, 2+= Normal, 3+=Increased/Bounding
Cap Refill: LUE: ____+1_______ RUE: _______+1____ LLE: ______+1_____RLE: __+1_________
Edema: LUE: ____+2_______ RUE: __+2_________ LLE: ____+2_______RLE: _____+2______
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NP=non-pitting, 1+=mild pitting, slight indentation, no perceptible swelling, 2+=Moderate pitting, indentation subsides rapidly, 3+=deep pitting, extremities looks swollen, 4+=Very deep pitting,
extremity is very swollen
Respiratory:
Effort: Unlabored Labored Accessory Muscle Use Retractions
Expansion: Symmetrical Asymmetrical
Cough: Non-Productive Productive Sputum: ______________________________________
Supplemental Oxygen (FiO2 and delivery device): ___________N/a_________________________________
Breath Sounds: clear, diminished
TH=Throughout, LUL=Left Upper Lobe, RUL=Right Upper Lobe, RML=Right Middle Lobe, LLL=Left Lower Lobe, RLL=Right Lower Lobe, Bil. Bases=Bilateral Bases

GI (gastro-intestinal):
Diet: _____normal__________________ G tube NG/ Dobbhoff tube N/V
Inspection: Flat Rounded Obese Distended Concave
Bowel Sounds:_______Active__________________________________________________________________
Active= 5-30x/min, Hypoactive=< 5x/min, Hyperactive=>30X/min, Absent=no sound heard after listening for 5 min.
Palpation: Soft Non-tender Tender Firm Guarding
Last BM: ___10/25/2022__________________ Consistency: Soft, formed Loose Hard Tarry
Color: Brown Black Green Red Other: _____________________
Ostomy present: _______________________________________________________________________

GU (genito-urinary):
Continent Incontinent Briefs Used F/C Suprapubic catheter Urostomy
BSC Urinal Bedpan Straight catheterization (specify frequency) ___________________________
Urine color/consistency:_____yellow (normal consistency)____________________________________________________________

Integumentary:
Skin Color: ______brown (normal for patients genetic background)_______________
Skin intact Excoriation Redness Ecchymosis

Psychosocial: (please circle all that apply)

Affect Consistent with mood Flat Affect Anxious Depressed Aggressive Agitated
Other:_____________________
Cultural Considerations:___older aged African American women, old school view on practices, respecting boundaries
(modesty)______________________________________________________________
Family Support: ______None__________________________________________________________________
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Date/Time Nurses Notes

10/26 8:20 Monitor room called pt. had 8 beats of vtach, pt. is comfortable in the bed, denies any chest pain or discomfort strips seen
by cardiology Dr. advised nothing, attending MD notified.
10/26 7:42 Called Joline pts. Guardian to get consent for blood transfusion , not answered and mailbox full, unable to leave message.
10/25 Pt. Hb 7.2 tried to call guardian for blood transfusion consent, gone to voicemail and it was full, tried three times and
15:53 called Essex for more information to reach guardian, they have the same number. Attending MD notified.
10/25 9:54 Attending MD returned the call advised to 500 ml n/s bolus over 1 hr. and to increase n/s at 100ml/hr and magnesium
sulphate 2gm IV one time.
10/25 9:37 BP 73/44 pt. comfortable in bed Mg 1.5, notified attending MD.
Note: Nurses Notes are for additional information not included in the assessment or worksheet, such as events or procedures done
during the shift. Do not chart any care here if already charted in other parts of this worksheet. PLEASE sign all notes with your first
initial, last name and credential (ULSN for UofL Student Nurse). Example: Pt wound 0.5 cm by 7 cm, well approximated with 8
sutures. P. Clark ULSN.

Nursing DX/Clinical
Problem
State the diagnosis/problem (the
unmet need) or potential problem and
what caused it if it is known. State the
diagnosis/problem clearly. The
diagnosis must be supported by the
data you have listed. Include only one
nursing problem per diagnosis. Be
sure to include etiological or
contributing factors.
Use the NANDA reference in order to
complete.
Assessment
Client Goals/Desired
Outcomes/Objectives
The goals should be realistic,
measurable, specific and
within a time frame.
They state: What the client is
to achieve, not what the nurse
is to do. They flow from the
diagnosis (nursing) and
should be aligned toward
meeting the identified unmet
need.
The Evaluation criteria are
University of Louisville
School of Nursing/ Care Plan Directions
Nursing
Interventions/Actions/Orders
And Rationale
The nursing interventions/actions/ orders
are what you are going to do to help the
client reach the objective/goal and thus
meet the unmet need. They should be
written in the present tense and be
specific enough that someone else could
carry them out. They should be written
as independent actions. Cite only those
actions that will help attain your stated
goal.
Be specific about what is to be done and
when. Be sure interventions/
*I Evaluation
Goals
Evaluate the client’s progress toward
attaining the goal by speaking to each
goal and/or the evaluation criteria.
State to what degree goals are met.
If the goals were not fully met, state what
further actions should be planned.
Revise the goal and/or evaluation criteria
as necessary.
Be sure to indicate reassessment data and
comment on your opinion regarding the
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Interventions
Evaluate the effectiveness of each one
of your interventions. Include in your
discussion whether you competed the
intervention, your rationale for either
using or not using the intervention
If the intervention was not helpful, state
what further actions should be planned.
Revise the intervention evaluation
criteria as necessary.
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Before writing the data you must
already have identified a nursing
problem area (unmet need). The facts
cited here support your diagnosis.
Include only data relevant to the
nursing diagnosis. Leave out unrelated
data.
Validate your perceptions rather than
include inferences.
Include subjective and objective data.
Data must be specific and complete,
given the information available.
those changes in the client
that indicate that the objective
has been met or partially met.
Be sure all goals are client
centered.
Use Nursing Outcomes
Classification (NOC).
actions/orders are concise and clear. need for revision.
Use Nursing Interventions Classification Be sure to include reevaluation and time
(NIC). frame when appropriate.
Include scientific rationale for each Be sure to reevaluate and/or revise
intervention/action/order. The rationale nursing diagnosis as necessary.
should indicate the pathophysiology
and/or psychosocial concept that support
each intervention/action/order. Be sure
the source for each rationale is cited.

Subjective Data:
Use client quotes

Objective Data:
Make sure to distinguish objective
data from medical interventions (i.e.
“morphine q 2 hours for pain” is an
intervention—whereas the fact that
the patients “pain is not relieved by
morphine q 2 hours” is objective data
to support acute pain that requires
nursing to take action).

*I = Implementation. Check those interventions/actions/orders that were implemented.

University of Louisville
School of Nursing
Care Plan

Assessment Nursing Client Goals/Desired Nursing *I Evaluation

Diagnosis/Clinical Outcomes/Objectives Interventions/Actions/Orders Goals Interventions
Problem and Rationale
Subjective Problem Long Term:

Objective
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Related to: Short Term:

As evidenced by:

*I = Implementation. Check those interventions/actions/orders that were implemented.

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References

Insert References Here in APA formatting (remember to do a hanging indent and double space)

Tucker, R. G. (2022). 2022 Lippincott Pocket Drug Guide for Nurses. Wolters Kluwer.

Drug forecast apixaban (eliquis) for treating and preventing thromboembolic disease. (2013).
P&t : A Peer-Reviewed Journal for Formulary Management, 38(4), 206–212.

NHS. (2021, December 17). Levothyroxine. NHS choices. Retrieved November 2, 2022, from
https://www.nhs.uk/medicines/levothyroxine/#:~:text=1.-,About%20levothyroxine,is%20only
%20available%20on%20prescription.