PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET
Student Name: Gladys Mireku
Week: 2
Dates of Care:5/20/2023
Patient Initials
CV
Sex
M
Age
47
Room
837
Admitting Date
5/19/2023
Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?
Intractable headache
Attending physician/Treatment team:
Ayman M. Jabr, MD
Consults:
No consult
Present Diagnosis: (Why patient is currently in the hospital)
Headache and dizziness
ER Management: (if applicable)
Nile Township high school
Allergies:
Shrimp, Ibuprofen, Aspirin
Code Status:
Full code
Isolation: (type and reason)
none
Admission Height:
165.1 centimeters (5,5)
Admission Weight:
107.9 kilograms (237 lbs)
Arm Band Location (colors & reasons)
on the right arm and it’s white
Communication needs: (verbal, nonverbal, barriers, languages)
the patient has no communication barriers
Past Medical History: (pertinent & how managed)
Diabetes Mellitus
Gerd
Hypertension
Obstructive Sleep Apnea
Sciatica
Spinal Stenosis
Degenerative Joint Disease
Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)
Tests/Treatments/Interventions impacting clinical day’s care (include current orders)
Assessments and interventions: (Include all pertinent data)
Vital signs: (2 sets per day)
Time
8: 00
T
98.6
P
96
R
18
B/P
138/80
Time
13: 00
T
97.9
P
98
R
20
B/P
111/73
GI:
Diet: Regular
Swallow precautions:
Tube feedings:
NG / G tube:
Blood Glucose: (time & date)
Last bowel movement: (time & date)
Pertinent Labs/Test:
Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)
Respiratory:
02 modalities:
02 Saturation: 96
Suction:
Resp Rx’s:
Trach: none
Chest Tubes: none
Pertinent Labs/Test:
Assessments/Interventions: (Lung sounds, cough, sputum, SOB)
Neurosensory:
Neuro checks:
Alert & Orientated: x4
Follows commands: yes
Speech Comprehensible: yes
Pertinent Labs/Test:
Assessments/Interventions:
(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)
patient had dizziness and headache
Cardiovascular:
Telemetry:
Pacemaker/IAD:
DVT Prevention: heparin (5000 units)
Daily Weights:
Pertinent Labs/Test:
Assessments/Interventions:
(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)
Musculoskeletal:
Activity: independent
Traction: none
Casts/Slings:
Pertinent Labs/Test:
Assessments/Interventions:
(strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps
Renal:
Catheter (indwelling/external):
CBI:
Dialysis:
A/V access:
Pertinent Labs/Test:
Assessments/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O)
Skin:
Braden Score:
Pertinent Labs/Test:
Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)
Pain:
Pain score: 10 in the head
Assessments/Interventions: acetaminophen was given
(scale used, location, duration, intensity, character, exacerbation, relief, interventions)
morphine
Vascular Access: (IV site)
Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)
Gyn:
Gravida/Para: none
LMP: none
Last Pap: none
Breast exam: none
Pertinent Labs/Test
Assessment/Interventions: (bleeding, discharge) none
Post-operative /procedural:
Assessments/Interventions: none
(immediate post procedure care)
Safety:
Call light:
Bed Rails:
Bed alarms: no need
Fall risk: not at 4 risk
Assistive Devices: none
Sitter use: none
Restraints (type, duration & reason):
Assessment/Interventions (modifications to room, environment, Patient)
Advance Directives/Ethical considerations:
DPOA: has no advanced directives
Hospice:
Pertinent Data (Labs, X-rays, Etc.)
Results
Normal Lab Values
Significance to your patient
WBC
7.2
5.2-12.4
RBC
5.37
4.7-6.2
HGB
17.3
12.0-15.0
HCT
48.9
37-50%
MCV
91.0
95.3
MCH
32.3
27-31
MCHC
35.5
32-36
Platelets
207
151-401
RDW
14.5
12-15%
MPV
8.3
7-9
CBC
PT
INR
APTT
Glucose
225
70-99
BUN
14
7-25
Creatinine
0.86
0.6-1.3
Sodium
134
135-145
Potassium
5.3
3.5-5.2
Cloride
97
98-107
Calcium
9.0
8.6-10.3
T Protein
6.4
Albumin
3.8
SGOT
SGPT
Alk Phos
69
Magnesium
Amylase
Lipase
CPK
LDH
Cholestrol
CK
CK-MB
Troponin I
Myoglobin
LDI
Urinalysis
Color
Character
Spec. Grav.
pH
Protein
Glucose
Acetone
Bilirubin
Blood
Nitr
Urobili
RBC
WBC
Epithelium
Urine Culture
Chest X-ray
MRI
CT Scan
Others test:
Psycho/Social: Assessment/Interventions:(mental illness, social history, living arrangements, primary care giver, substance abuse, maternal/infant bonding, family dynamics)
Cultural/Spiritual needs: Assessment/Interventions: (religious preference, adaptations & modifications, end of life decisions)
Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient:
Current overall plan of care: (A short statement that summarizes the anticipated plan of care)
Discharge plans and needs:
Teaching needs:(Disease process, medications, safety, style, barriers)
Pathophysiological Discussion: Discuss the current disease process at the cellular level (in your own words). Explain why this patient is encountering this particular health deficit. What is the relationship of this current health alteration to the patient’s other medical conditions? Describe the current disease process the patient is encountering etiology, epidemiology, pathophysical mechanism, manifestations and treatment (medical and surgical). Also note the complications that may occur with these treatments and the patient’s overall prognosis. Include appropriate references and use APA format.
Attach a research article pertaining to diagnosis of patient. Write a summary about the article.
The study was about proportion of people suffering from headache and dizziness during the prodromal stage of migraine and the related effects. Approximately one third experience headache phase-associated dizziness or vertigo, with similar rates for both symptoms. The findings from the meta-analysis indicate the current research criteria for vestibular migraine may be inadequate, as migraine patients where dizziness is the primary manifestation of the vestibular symptom might be overlooked. However, methodological variations confound comparisons of epidemiological patterns. Future studies should use rigorous methodology and adhere to standardized definitions to enable accurate measurements of vestibular symptoms during both the prodromal phase and headache phase of migraine.
Iljazi, A., Ashina, H., Lipton, R. B., Chaudhry, B., Al-Khazali, H. M., Naples, J. G., … & Ashina, S. (2020). Dizziness and vertigo during the prodromal phase and headache phase of migraine: A systematic review and meta-analysis. Cephalalgia, 40(10), 1095-1103.
List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting. May only list one nursing diagnosis that is a Risk For diagnosis.
Priority
Nursing Diagnosis
Related to
As Evidence By
Rationale (reason for priority)
1
Acute pain
Acute pain related to or coming from a medical problem
Evidenced by patient verbalizing pain and rating the pain at 10 in a numeric pain scale
Pain results in an unpleasant sensory and emotional experience which is a risk to potential tissue damage due to unpredictable events following pain effects.
2
Imbalanced nutrition more than the body requirements
Imbalanced nutrition related to imbalanced nutrient intake due to a metabolic disorder.
Evidenced by basal metabolic index of 39.6.
Obesity is a major risk factor to some conditions in the body. It exacerbates the severity of diseases such as diabetes mellitus and hypertension. Managing obesity improves the prognosis to patients suffering from these conditions and many others
3
Risk of infection
Risk of infection related to a possible site of organism invasion-indwelling catheter
Indwelling catheterization is a procedure which, if aseptic technique and hygiene is not properly observed may be a possible site for organism invasion and therefore risk a patient to an infection.
4
5
Medications
Classification
Dose
Route
Freq
Purpose/Mechanism of Action
Significant Side Effects / Adverse Reactions
Nursing Implications
Ascorbic acid (Vitamin C)
100 mg tablet
Oral
Daily
Atorvastatin (Lipitor)
10 mg tablet
Oral
Daily
Dexamethasone (Decdron)
8mg IM
Injection
Intravenous
Acetaminophen
650 mg
Orally
PRN
Diphenhydramin (Benadryl)
25 mg injection
Injection
Intravenous
Enalapril (Vasotech)
10 mg
Oral
Daily
Furosemide (Lasix)
40 mg
Oral
Daily
Glucagon
1 mg
IM
PRN
Heparin
5000 units
IM
Continuous
Insulin Aspart (Novolog)
18 units
IM, Subcontanous
3 times daily with meals
Nursing Diagnosis: Identify the top two nursing Diagnoses and expand
Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)
Patient Goal(s)
Statement of purpose for the patient to achieve
Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)
(Must have at least two short term outcomes and two long term outcomes)
Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.
Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)
Acute Pain
Patient describes satisfactory pain control of less than 3 in the same numeric pain scale
1. Patient will exhibit signs of pain relief within 30 minutes
2. Patient displays improved wellbeing, mood and coping.
3. Patient remains comfortable with no pain disturbance.
1. Administer analgesics i.e. acetaminophen. They work by blocking the synthesis of prostaglandins which stimulate nociceptors thereby relieving pain.
2. Provide rest periods to promote rest relief and sleep. Ones experiences of pain may become exaggerated as a result of exhaustion. A peaceful and quiet environment may stimulate pain relief
3. Get rid of stressors or any form of discomfort by all means possible. A patient may experience an exaggerated painful situation if exposed to stressors leading to further pain.
Patient could now rate pain at 2 in a numeric pain scale of one to ten. Patient exhibited signs of comfort.
Nursing Diagnosis: Identify the top two nursing Diagnoses and expand
Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)
Patient Goal(s)
Statement of purpose for the patient to achieve
Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)
(Must have at least two short term outcomes and two long term outcomes)
Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.
Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)
Imbalanced nutrition more than body requirements
Patient designs a dietary modification to achieve weight control.
1. Patient knows the necessary dietary modifications so as to reduce weight.
2. Patient will verbalize accurate information on benefits of weight loss.
3. Patient will maintain an overall balanced nutrition
1. Negotiate as well as educate the patient the aspects of his diet that require to be modified. Such negotiations and agreements with the patients allow harmonious care to the patient and hence a good prognosis.
2. Educate the patient on risks associated with obesity. Informed decisions are important in the patient’s own decision making on issues that will affect him.
3. Suggest to the patient to keep a diary of food intake and the circumstances surrounding its consumption. Self-monitoring helps the patient assess self-adherence to self-determined performance criteria and progress towards desired goals
Patient reduced weight; patient nutritional status was maintained at balanced state.
