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CLIENT INFORMATION SHEET (CIS)
Student Name____Joel Polanco_______
Patient Initials____FB__
MX
Date___06/03/2015
F Age___80___ Religion_Catholic_ Primary Language__English____
Allergies________NKA_____________ DNR AD None
Weight___________________
Admission Date___06/01/2015__________
Height_____5’11”__________
Admission Diagnosis___Lumbar disc herniation_________
Current Diagnosis [reason for admit/chief complaint ___Back Pain
Surgical/Invasive Diagnostic Procedures [this admit]_____Endoscopy, L1L2
Discectomy_________________________________________________
Concurrent Medical History [past]_____Lumbar stenosis, gout
Past Surgeries______c-spine sx c6-c7, 4 different lumbar
Course of Hospitalization [what happened during stay]___pt was hospitalized and operated on the next day (discectomy
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Precautions/Special Needs [isolation, fall, restraints]_____Fall risk_____Activity Order_____
External Devices [orthopedic, SCD/IPC]______________________________________________________________________
Treatments [wound care, 02]__________________________________________________________________________
Vital Signs: frequency___q4h_ BP_117/80________T___98.0______P____82____R___18____ Baseline___
Diet___normal/oral
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Tube Feeding: type, rate/frequency, site____________________________________________
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Intake:
Output:
Oral_______________Oral
Urine/Foley/Incontinent/Voids___Voids_____________________
Parenteral____________NA______________
Drainage tubes [specify]___________NA__________________
Tube Feed_______NA___________________
Other: ___________________________________________
Other:____________________________________________
Q 8 H or Q 12 H or Q________H
Total Input___300____
Total Output__400
Venous Access Devices:
[type, solution, rate/saline lock, site]
BS Glucose: AM____________ PM_______________
PIV___Right hand_____________________________________
CVC _______________________________________________________________________________________________________
Other:______________________________________________________________________________________________________
Pathophysiology of Medical Problem [describe etiology, progression, treatment-specific to client]:
_The cause of spinal stenosis in the lumbar spine is commonly associated with aging. The facet jointa (small stabilizing
joints located between and behind vertebrae) tend to get larger as they degenerate and can compress the spinal nerve
roots in the lower back, often producing lumbar stenosis symptoms of pain, especially with
activity._______________________________________________________________________________________________
__
Consultations [type, date, results]______________________________________________________________________
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Current Lab Results:
Normal
Na+
135-145
K+
3.5-5
Cl`
95-105
CO2
22-26
Glu
65-139
Ca+
8.5-10.5
BUN
8-21
Cr
0.6-1.2
Note Additional Diagnostic Studies Below (Radiographs, Scans, etc.)
•
N
•
P
•
Significance of
Results
Abnormals: [indicates kidney failure, anemia, etc.]
•
N
•
B
•
134
•
K
3.6
•
•
97C
•
•
28C
•
•
90G
•
•
C
7.7
•
•
•
6 B Abnormal most• likely due to diminished gfr rate and renal
function with age
C Abnormal most
0.54
• likely due to diminished gfr rate and
renal function with age
M
1.8
•
•
W
8.4
•
H low, probably due
9.1
• to blood loss during surgery
•
H low, probably •due to blood loss during surgery
27.7
•
P
158
•
29/13.7/1.00
•
•
Mag+ 1.6-2.6
WBC
4.5-11
HgB
11.7-17.3
HcT
33-39
Plt
150450x109/L
PTT/PT/INR
•
•
O
•
•
•
O
•
•
•
O
•
•
Other:
Other:
Other:
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4
•
O
•
•
Other:
Medications: List only [complete on medication form]
Bisacodyl 10 mg, diphenhydramine 25 mg
_____________________________________________________________________________________
Nursing Diagnosis: [list 3 & prioritize]
1. Acute pain related to surgical procedure evidenced by narrowed focus.
2. Impaired physical mobility related to pain and discomfort evidenced by discomfort on movement.
3. Deficient knowledge related to information misinterpretation evidenced by request for information
All Nursing interventions/actions:
1. Patient will take over the counter nsaid pain medications.
2. Patient will follow a rest and limited exercise regimen.
3. Patient will be educated on exercise schedule, walker use, medication compliance and adl maintenance.
Anticipated Discharge Needs: [equipment; include teaching]
1. Instructions on bathing, exercising and dieting regimen.
2. Patient will use a walker for a period of four weeks
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References [APA] Attach Additional Sheets As Necessary For Any of Above.
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UNDERGRADUATE MEDICATION FORM
Drug, (Class, Generic/Trade Name, order date)
Dose:
Pharmacological Action and Side Effects/Contraindications
desired in client (why is
this client on this med?)
Safe Range
Nursing Actions (Individualized to
patient)
Expected Outcome
Specify how to administer the Medication
Was outcome achieved-provide evidence
Route:
Time :
Bisacodyl- Treatment of constipation. Evacuation of the Stimulates peristalsis.
Alters fluid and
bowel before radiologic studies or surgery. Part of a
electrolyte transport,
bowel regimen in spinal cord injury patients.
producing fluid
accumulation in the
colon. Therapeutic
Effects: Evacuation of the
colon.
Diphenhydramine- Relief of allergic symptoms caused
by histamine release including: Anaphylaxis, Seasonal
and perennial allergic rhinitis, Allergic dermatoses.
Parkinson’s disease and dystonic reactions from
medications. Mildnight time sedation. Prevention of
motion sickness. Antitussive (syrup only).
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Patient will take drug once a day in order to evacuate.
GI: abdominal cramps, nausea,
diarrhea, rectal burning.
F and E: hypokalemia (with chronic
use). MS: muscle weakness (with
chronic use). Misc: proteinlosing
enteropathy, tetany (with chronic use).
Antagonizes the effects of CNS: drowsiness, dizziness,
histamine at H1-receptor headache, paradoxical
sites; does not bind to or excitation (increased in children).
inactivate histamine.
EENT: blurred vision, tinnitus. CV:
Significant CNS
hypotension, palpitations. GI:
depressant and
anorexia, dry mouth, constipation,
anticholinergic
nausea. GU: dysuria, frequency,
properties.
urinary retention. Derm:
Therapeutic Effects:
photosensitivity. Resp: chest
Decreased symptoms of tightness, thickened bronchial
histamine excess
(sneezing, rhinorrhea,
nasal and ocular
pruritus, ocular tearing
and redness, urticaria).
Relief of acute dystonic
reactions. Prevention of
motion sickness.
Suppression of cough.
Patient will take over the counter antihistamine as
prophylaxis for allergic dermatitis.
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Reference
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Note: This section must be individualized to patient
Nursing Diagnosis:
_____________________________________________________________________________
________________
Assessment data
Planning and Implementation Phase
Rationale
(Cite References)
Goals
Interventions
(1 Long, 2 Short Term) (Min. of 4 per goal)
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EVALUATION: Two satisfactory care plans
UNIVERSITY OF MIAMI SCHOOL OF NURSING NUR308
Name_________________________________________
Faculty______________________________________
DATE
NOTE: One Satisfactory CP must be completed prior to midterm
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1.
Care plans must be organized, concise and legible.
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2.
Patient information sheet is complete and comprehensive.
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3.
Assessment data are derived from a variety of sources, i.e., client,
chart, family, other health team members, etc.
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4.
Assessment data are comprehensive, includes subjective and objective 5
data, and supports the nursing diagnoses.
5.
The nursing diagnoses is comprehensive, reflects priority
current/potential client problem.
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6.
Nursing diagnosis is correctly stated.
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7.
Objectives are realistic.
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8.
Objectives are measurable and written as client behaviors.
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9.
Nursing interventions are individualized and comprehensive.
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10.
Nursing interventions are culturally sensitive.
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11.
Nursing interventions correspond to the objectives.
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12. Nursing interventions include client/family teaching.
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Pathophysiology is comprehensive and supports the priority problem.
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Nursing interventions are explained thoroughly.
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Pharmacologic interventions are accurate and individualized with
appropriate nursing actions for patient safety.
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16. Rationales support nursing interventions.
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17. Evaluation indicates how objectives were achieved and whether they
were realistic or if they needed modification.
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2
Comments
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NOTE: One Satisfactory CP must be completed prior to midterm
18. Uses appropriate APA format for referencing
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5
100
Student must receive a minimum of 85% to pass.
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2
Comments