PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET
Student Name:
Week:
Dates of Care:
Patient Initials
E.R
Sex
M
Age
74
Room
1012
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)
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
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)
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)
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
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:
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)
Gyn:
Gravida/Para:
LMP:
Last Pap:
Breast exam:
Pertinent Labs/Test
Assessment/Interventions: (bleeding, discharge)
Post-operative /procedural:
Assessments/Interventions:
(immediate post procedure care)
Safety:
Call light:
Bed Rails:
Bed alarms:
Fall risk:
Helpive Devices:
Sitter use:
Restraints (type, duration & reason):
Assessment/Interventions (modifications to room, environment, Patient)
Advance Directives/Ethical considerations:
DPOA:
Hospice:
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:
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.
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.
Priority
Nursing Diagnosis
Related to
As Evidence By
Rationale (reason for priority)
1
2
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.
Assessment. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new Assessment date/time is set)
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.
Assessment. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new Assessment date/time is set)
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PATIENT/CLIENT DATA – WORKSHEET FOR CLINICAL DECISION-MAKING
Name of the student:
Week:
Dates of Care:
Patient Initials
E.R
Sex
M
Age
74
Room
1012
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
