PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET
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Student Name: |
Week: |
Dates of Care: |
Patient Initials
E.R
Sex
M
Age
7
4
Room
1
01
2
Admitting Date
1/9/2022
Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?
Chest PAIN, SOB
Attending physician/Treatment team:
Juan C Villamizar. MD
Consults:
Respiratory Therapist
Present Diagnosis: (Why patient is currently in the hospital)
Pneumonia due to Covid-19
ER Management: (if applicable)
Allergies:
Code Status:
Full Code
Isolation: (type and reason)
Contact and Droplet
Admission Height:
5
’10
Admission Weight:
144
Arm Band Location (colors & reasons)
Communication needs: (verbal, nonverbal, barriers, languages)
Spanish/English
Past Medical History: (pertinent & how managed)
Diabetes type 2, HTN, Pneumonia, acute kidney injury, CVA, Oropharyngeal dysphagia, smoker
Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)
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Tests/Treatments/Interventions impacting clinical day’s care (include current orders) |
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Assessments and interventions: (Include all pertinent data) |
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Vital signs: (2 sets per day) Time 0712 T 96.6 P 89 R 16 B/P 108/62 Time T P R B/P |
GI: Diet: 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) |
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Respiratory: 02 modalities: 02 Saturation: Suction: Resp Rx’s: Trach: Chest Tubes: Pertinent Labs/Test: Assessments/Interventions: (Lung sounds, cough, sputum, SOB) |
Neurosensory: Neuro checks: Alert & Orientated: Follows commands: Speech Comprehensible: Pertinent Labs/Test: Assessments/Interventions: (LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness) |
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Cardiovascular: Telemetry: Pacemaker/IAD: DVT Prevention: Daily Weights: Pertinent Labs/Test: Assessments/Interventions: (peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations) |
Musculoskeletal: Activity: Traction: Casts/Slings: Pertinent Labs/Test: Assessments/Interventions: (strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps |
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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) |
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Pain: Pain score: Assessments/Interventions: (scale used, location, duration, intensity, character, exacerbation, relief, interventions) |
Vascular Access: (IV site) Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance) |
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Gyn: Gravida/Para: LMP: Last Pap: Breast exam: Pertinent Labs/Test Assessment/Interventions: (bleeding, discharge) |
Post-operative /procedural: Assessments/Interventions: (immediate post procedure care) |
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Safety: Call light: Bed Rails: Bed alarms: Fall risk: Assistive Devices: Sitter use: Restraints (type, duration & reason): Assessment/Interventions (modifications to room, environment, Patient) |
Advance Directives/Ethical considerations: DPOA: Hospice: |
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Pertinent Data (Labs, X-rays, Etc.) Results Normal Lab Values Significance to your patient WBC RBC HGB HCT MCV MCH MCHC Platelets RDW MPV PT INR APTT Glucose BUN Creatinine Sodium Potassium Cloride Calcium T Protein Albumin SGOT SGPT Alk Phos 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: |
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Psycho/Social: Assessment/Interventions:(mental illness, social history, living arrangements, primary care giver, substance abuse, maternal/infant bonding, family dynamics) |
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Cultural/Spiritual needs: Assessment/Interventions: (religious preference, adaptations & modifications, end of life decisions) |
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Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient: |
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Current overall plan of care: (A short statement that summarizes the anticipated plan of care) |
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Discharge plans and needs: |
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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.
ADH II: attach a research article pertaining to diagnosis of patient. Write a summary about the article.
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.
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Priority |
Nursing Diagnosis |
Related to |
As Evidence By |
Rationale (reason for priority) |
| 1 | ||||
| 2 | ||||
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3 |
||||
| 4 | ||||
| 5 |
| Medications | Classification | Dose | Route |
Freq |
Purpose/Mechanism of Action | Significant Side Effects / Adverse Reactions | Nursing Implications |
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) | |||
Nursing Diagnosis: Identify the top two nursing Diagnoses and expand
|
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) |
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1
PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET
Student Name:
Week: 6
Dates of Care:
3
/06/
2
1
|
Patient Initials E.J |
Sex F |
Age 73 years old |
Room 4 1 |
Admitting Date 3/04/2021 |
Admitting Chief Complaint: What symptoms cause the patient to come to the hospital? Diarrhea , abdominal pain |
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Attending physician/Treatment team: Ahmad Alwakkaf, MD Brandon M O’Malley, MD Natalie, Nurse Louie Chua, Physical therapist |
Consults: gastroenterologist Respiration therapist |
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Present Diagnosis: (Why patient is currently in the hospital) Acute colitis |
ER Management: (if applicable) The patient was rushed to ER due to frequent loose, watery stools and belly pain. |
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Allergies: Pork, beef, erythromycin |
Code Status: Full |
Isolation: (type and reason) None. Not contagious on proximity |
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Admission Height: 17 5 .3cm |
Admission Weight: 55.8kg |
Arm Band Location (colors & reasons) Right hand. White |
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Communication needs: (verbal, nonverbal, barriers, languages) 1. Explain the importance of each medication administered. 2. Inform the patient of likely side effects of medications. 3. The patient’s preferred language is English. |
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Past Medical History: (pertinent & how managed) 1. Bloody diarrhea- fluid administration, antidiarrheic meds 2. Seizures- anti-epileptic meds 3. Infectious colitis- antibiotics administration |
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Significant Events during this hospitalization but not during this clinical time: (include the date, event, and outcome) 1. Lactic acid once on 3/06/2021 2. C. dif. Screening on 3/05/2021 |
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Tests/Treatments/Interventions impacting clinical day’s care (include current orders) 1. Vital signs every 4 hours 2. Intake and output every shift. 3. Maintain sequential compression device. 4. Height and weight once daily |
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Assessments and interventions: (Include all pertinent data) |
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Vital signs: (2 sets per day) 3/06/2021 Time 1440 2026 T 99℉ (Auxiliary) 98.9℉ (Auxiliary) P 76 beats/min(monitor) 81 beats/min(monitor) R 19beats/min(monitor) 19beats/min(monitor) B/P 90/53 mmHg (right arm) 100/59 mmHg (right arm) 3/06/2021 Time 1812 2034 T 97.9℉ (Auxiliary) 98.2℉ (Auxiliary) P 66 beats/min(monitor) 76 beats/min(monitor) R 18 beats/min(monitor) 17 beats/min(monitor) B/P 101/64 mmHg (right arm) 114/72 mmHg (right arm) |
GI: Diet: Clear liquid Swallow precautions: for solids Tube feedings: none NG / G tube: none Blood Glucose: (time & date)- 170mg/dL. 10am. 3/06/2021. Last bowel movement: (time & date)- 5pm. 3/06/20. Pertinent Labs/Test: None Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting) I did a 5min assessment on this patient, however, I also noticed that his stool was brown and soft inconsistency. The patient did not report feeling nauseous or wanting to vomit. |
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Respiratory: 16 breath/min 02 modalities: room air 02 Saturation: 95% Suction: none Resp Rx’s: none Trachodont Chest Tubes: none Pertinent Labs/Test: none Assessments/Interventions: (Lung sounds, cough, sputum, SOB)- clear lungs sounds, no SOB. |
Neurosensory: Alert x4 Neuro checks: Yes Alert & Orientated: alert and oriented x4 Follows commands: yes. Speech Comprehensible: yes Pertinent Labs/Test: none Assessments/Interventions: (LOC, pupils, Glasgow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)- good LOC, dilated pupils, no dizziness, or headaches |
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Cardiovascular: Telemetry: none Pacemaker/IAD: none DVT Prevention: none Daily Weights: 55.8kg Pertinent Labs/Test: Assessments/Interventions: (peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)- radial pulse; +2, strong and normal rhythm/ |
Musculoskeletal: Activity: Limited Traction: none Casts/Slings: none Pertinent Labs/Test: none Assessments/Interventions: (strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps – good muscle strength, good ROM, the pain of 7 out of 10, no fractures or amputation. The patient was able to hold my two-finger and pushed down against resistance. |
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Renal: Catheter (indwelling/external): none CBI: none Dialysis: none A/V access: none Pertinent Labs/Test: none Assessments/Interventions: (location, bruit, thrill) (urine-quality, burning with urination, hematuria, incontinent, continent, I & O)- good urination. |
Skin: Braden Score: 14 Pertinent Labs/Test: Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toenails, wounds, drains, bed type)- intact skin, poor skin turgor, finer, and nails fine. |
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Pain: Pain score: 7 Assessments/Interventions: (scale used, location, duration, intensity, character, exacerbation, relief, interventions)- scale of 0 to 10 for pain. O being the lowest pain and 10 the highest. |
Vascular Access: (IV site) Assessments/Interventions: (include the type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)- 20ml/kg isotonic sodium chloride. 0.9%. IV site has assessed no phlebitis, redness, or skin breakdown. An IV catheter was not due for a change. The skin was intact. |
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Gyn: Gravida/Para: none LMP: none Last Pap: none Breast exam: none Pertinent Labs/Test: none Assessment/Interventions: (bleeding, discharge): none |
Post-operative /procedural: Assessments/Interventions: (immediate post-procedure care)- no surgery is done. |
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Safety: Call light: was given to the patient aftercare. Bed Rails: one side was taken up. Bed alarms: none Fall risk: Not at for fall. Assistive Devices: none Sitter use: none Restraints (type, duration & reason): none Assessment/Interventions (modifications to room, environment, Patient): none |
Advance Directives/Ethical considerations: DPOA: none Hospice: none |
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Pertinent Data (Labs, X-rays, Etc.) Results Normal Lab Values Significance to your patient WBC 12.9 4.0 – 11.0 RBC 4.19 4.34 – 5.60 HGB 16.1 13.0 – 17.0 HCT 39.2 38.6 – 49.2 MCV 94.6 80.0 – 100.0 MCH 31.6 26.0 – 34.8 MCHC 33.4 32.5 – 35.8 Platelets 374.7 150 – 450 RDW 15 11.9 – 15.9 MPV 8.8 6.8 – 10.2 PT INR APTT Glucose 83 70 – 99 BUN 12 7-20 Creatinine 0.54 0.59 – 1.04 Sodium 137 135 – 145 Potassium 3.7 3.5 – 5 Chloride Calcium T Protein Albumin SGOT SGPT Alk Phos Magnesium Amylase Lipase 115 11-82 CPK LDH Cholesterol CK CK-MB Troponin I Myoglobin LDI Urinalysis Color yellow Character Spec. Grav. pH Protein 6.8 Glucose 150 90 -120mg/dl Acetone Bilirubin Blood Nitro Urobili RBC WBC Epithelium Urine Culture Chest X-ray MRI CT Scan Others test: |
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Psycho/Social: Assessment/Interventions:(mental illness, social history, living arrangements, primary caregiver, substance abuse, maternal/infant bonding, family dynamics) No mental illness. |
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Cultural/Spiritual needs: Assessment/Interventions: (religious preference, adaptations & modifications, end of life decisions) No religious, or cultural preference |
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Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorists) What stage of development evident with the patient: fully alert, a little bit is withdrawn from the society. |
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The current overall plan of care: (A short statement that summarizes the anticipated plan of care)- includes control of diarrhea and promoting optimal bowel function; minimize or prevent complications; promote optimal nutrition and provide information about the disease process and treatment needs to the patient. |
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Discharge plans and needs: The patient should be discharged on the 6th of March 2021. According to her medical record, a follow-up appointment was made to reevaluate her progress after a month. The patient will have her belongings well accounted for by the time of discharge. |
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Teaching needs:(disease process, medications, safety, style, barriers) The patient will be educated on the disease process. The patient will be taught to identify and restrict foods and fluids that precipitate diarrhea (vegetables and fruits, whole-grain cereals, condiments, carbonated drinks, milk products). Provide written educational materials on various aspects of pain control to improve client understanding of pain and pain-related interventions. Explain lifestyle changes that will help relieve pain. |
Pathophysiological Discussion: Discuss the current disease process at the cellular level (in your own words). Explain why this patient is encountering this 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, pathophysiology 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.
ADH II: attach a research article about the diagnosis of a patient. Write a summary of the article.
· ETIOLOGY: infection, for example, caused by bacteria like C. difficile, viruses, and parasites; inflammatory bowel disease like Crohn’s disease and ulcerative colitis; ischemic colitis caused by decreased blood supply; microscopic colitis (lymphocytic/collagenous); allergic reactions.
EPIDEMIOLOGY: The prevalence is lower in developing countries. In Asian populations, for example, the prevalence ranges from 5.3 to 63.6 per 100000 people, whereas in North America, it ranges from 37.5 to 238 per 100000 people. In addition to the gradient between its occurrence in West and Asian countries, it has been noted that in Europe, although there are exceptions, there is also a geographical gradient for the incidence of IBD, with higher rates in the north and a lower frequency in the south. (Florin TH, 2004).
PATHOPHYSIOLOGY: Inflammation in ulcerative colitis involves the rectum in 95% of patients and extends proximally in a continuous pattern. The disease may affect the entire colorectum (termed pancolitis) or only be limited to the rectum (termed proctitis). Some patients may develop limited terminal ileal involvement (backwash ileitis) that can be challenging to differentiate from Crohn’s disease. (Jessurun, 2017).
MANIFESTATION AND TREATMENT: A combination of history, assessment of endoscopic and radiological appearances, histology, and microbiology is needed to diagnose colitis. The cardinal symptoms of ulcerative colitis are bloody diarrhea, urgency, tenesmus (straining at stool).
Mild distal colitis, in which rectal bleeding may be absent, can mimic irritable bowel syndrome. Colicky lower abdominal pain may occur, but severe pain is usually limited to severe colitis.
Stool cultures should be performed (particularly for Clostridium difficile toxin) even in patients with a relapse of known ulcerative colitis.
The presence of bloody diarrhea for more than three weeks should alert the doctor to the possibility of inflammatory bowel disease, and endoscopy should be performed. Treatment includes- Sulfasalazine, Corticosteroids, thiopurines amongst others. (Cohen RD, 2000).
ADH II:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1539087/
Above is a link to the article on the diagnosis of acute colitis. It shows what causes acute colitis, who gets it, how to identify it- using cardinal symptoms such as bloody diarrhea, urgency, tenesmus. It also explains other extraintestinal manifestations.
REFERENCES
· Florin TH, Pandeya N, Radford-Smith GL. Epidemiology of appendicectomy in primary sclerosing cholangitis and ulcerative colitis: its influence on the clinical behavior of these diseases. Gut. 2004; 53:973–979.
· Jessurun J. The Differential Diagnosis of Acute Colitis: Clues to a Specific Diagnosis. Surg Pathol Clin. 2017 Dec;10(4):863-885
· Cohen RD, Woseth DM, Thisted RA, Hanauer SB. A meta-analysis and overview of the literature on treatment options for left-sided ulcerative colitis and ulcerative proctitis. Am J Gastroenterol 2000;95: 1263-76
List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide a rationale for priority setting. May only list one nursing diagnosis that is a Risk For diagnosis.
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Priority |
Nursing Diagnosis |
Related to |
As Evidence By |
Rationale (reason for priority) |
| 1 | Diarrhea |
Inflammation of the colon |
Watery stool |
Relates to circulation. Urgent to prevent hypovolemic shock |
| 2 |
Acute pain |
Inflammation of colon |
Abdominal pain of a 7 out of 10 |
Pain should be taken care of to make the patient cooperative |
| 3 |
Risk for deficient fluid volume |
Inadequate water intake |
Dry mucous membrane |
This should be taken care of to prevent deficient fluid volume |
|
Fear |
Learned response to a threat |
Past medical history of infectious colitis |
A psychosocial diagnosis should be taken care of as soon as stability is established. |
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| 5 |
Lack of readiness to learn. |
frequent hospitalizations |
Refusal to listen to teachings |
This should be addressed so the patient can learn how to manage their health |
| Medications | Classification | Dose | Route |
Freq |
Purpose/Mechanism of Action | Significant Side Effects / Adverse Reactions | Nursing Implications | ||||||
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1) Aspirin |
NSAID |
81mg |
oral |
Once-daily |
1.Pain relief 2. Anti-inflammation 3. Blocks PG synthesis |
1.Upset stomach. 2. Stomach ulcers 3. Swelling of skin tissues. |
1. Monitor potassium levels daily 2. Assess the patient for signs of bleeding daily. |
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2) Atorvastatin |
Statins (HMG – CoA reductase inhibitors) |
20mg |
1.Prevent cardiovascular disease. 2. Treatment of dyslipidemia 3. Inhibits HMG-CoA |
1. Liver problems 2. Diabetes |
1.Monitor liver enzymes daily 2. Monitor blood glucose level daily |
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3. Diltiazem |
Calcium channel blocker |
30mg |
1. Treat high blood pressure. 2. Treat angina. 3. Inhibits calcium ions inflow into smooth muscle |
1.Hypotension 2. Bradycardia 3. Dizziness |
1. Monitor blood pressure before therapy 2. Monitor ECG continuously |
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4. Hydromorphone |
Opioid analgesics |
1mg |
IV |
PRN Q4H |
1.Treat severe pain. 2. Anesthesia 3. Acts on the opioid mu receptor |
1. Respiratory depression 2. Dizziness 3. Constipation |
1. Monitor respiratory rate daily. 2. Encourage the patient to sit on the bed for a while before getting up. |
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5.Levetiracetam |
Anticonvulsant |
500mg |
BID |
1.Treat epilepsy 2. Treat tonic-colonic seizures 3. Binds synaptic vesicle protein in the brain to moderate synaptic neurotransmitter release. |
1.Psychosis 2. Suicide 3. Anaphylaxis |
1.Monitor the patient for abnormal behaviors. 2. Educate the patient on expected side effects. 3. Encourage the patient to speak with loved ones often. |
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6). Paroxetine |
SSRIs/ Antidepressants |
10mg |
QAM |
1.Treat depression 2. Treat panic disorder 3. Treat PTSD |
1. Suicide 2. Dysfunction 3. Headaches |
1.Monitor for worsening of depression. 2. Monitor for headaches |
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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 time, 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 a new evaluation date/time is set) |
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1. Diarrhea r/t gastrointestinal disorders as evidenced by a discharge of watery stools. 2.Acute pain r/t inflammation of the colon as evidenced by abdominal pain of 7 out of 10 on a scale of 0 to 10. |
A patient will defecate formed soft stool every 1 to 2 days. The patient will describe pain at a level of 3 or less on a rating of 0 to 10 at the time of discharge. |
1). The patient will defecate formed soft stool every 1 to 2 days. 2). Diarrhea will stop within 24 hours. 1). The patient will be relieved of pain and attain a desirable pain level of 3 or less on a scale of 0 to 10 by the time of discharge. 2). The patient will describe non-pharmacological methods to relieve pain by the time of discharge. |
1)i. Monitor pattern of defecation to notice daily changes. ii. inspect, auscultate, and palpate the abdomen to observe improvements daily. 2)i. Assess for feeding and medication history to inciting factors daily. ii. Monitor food and fluid intake to prevent worsened conditions daily. 1)i. Conduct and document a comprehensive pain assessment daily to observe improvements daily. ii. Ask the client to describe prior experiences with pain to identify factors that show the client’s description of pain evidenced by anxiety daily. 2)i. Give a warm bath daily to reduce pain. ii. Teach patient non-pharmacological methods to relieve pain daily. |
Goals are met. Goals are met. |
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