Student Name: Nurse Nancy SVN
Patient Initials: JDS
Age: 86
Clinical Prep Sheet
Unit: 3-East
Date: 01/01/2012 Clinical Wk#_1
Allergies: NKDA_________________________________
Medical Diagnosis for Admission to the Hospital
Pathophysiology /Etiology/Cause for Medical Diagnosis
Primary Diagnosis and additional diagnosis
1.
2.
3.
Short patho about primary diagnosis if needed attached
additional page
Chest Pain
Hypertension
DM
Findings to be reported to HCP
HCP Orders
Based on medical diagnosis and nursing diagnoses, what
complications could occur and what you would report to the
primary nurse and /or HCP
 Worsening skin integrity
 Purulent drainage from wound
 Elevated temperature
 Abnormal lab values
 Abnormal VS
 Increase pain/discomfort
Place physician orders here that pertain to your patient
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Wound Care Nurse Consult
Foley Catheter
Physical Therapy consult
Diet:
Treatments:
Activity Level
Restrictions:
Collaborative Care:
Lab Data
Xrays / Procedures (Results)
Test/Exams that relate to your patients diagnosis and the
normal and results of the exams.
 Glucose- 280
 CBC (H/H; WBC;RBC)
 BUN – 26
 Creatinine- 2.0
 Electrolytes
 Urinalysis
Chest Xray (CXR) – Bilateral lower lobe infiltrates
Nursing Assessment Findings
Textbook (Source)
According to your textbook what is the signs and symptoms
of the medical diagnosis and nursing diagnosis
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Pressure or aching in chest
Constrictive, squeezing, heavy choking or suffocating
sensation
Location sub sternal with radiating into neck, jaw
and down arms.
Pain lasts for only a few minutes (5 to 15 min)
Pain occurs during activity or has a precipitating
factor
Pain at rest is unusual
Diaphoresis
Shortness of breath
Lewis, (p.772)
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Patient Specific
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C/O of sharp pain
Denies any squeezing or suffocating sensation
Location right upper chest with no radiation, no redness,
bruising or injury noted in right upper chest. No masses or
tenderness noted upon palpation.
Pain last several hours, denies and nausea or vomiting
Pain occurs after eating
Pain during activity and rest, no restriction in activity or
ADLS
Skin warm and dry, color pink
Denies any shortness of breath, lungs clear to auscultation
bilaterally. Respiration regular and unlabored at 18
What is the assessment data, signs and symptoms that your
patient exhibits. This is objective and subjective data. It also
can be retrieved from the MD’s admission notes, History and
Physical, Emergency Room record; admission nurses notes,
patient, family and your assessment.
Student Name: Nurse Nancy SVN
Patient Initials: JDS
Age: 86
Clinical Prep Sheet
Unit: 3-East
Date: 01/01/2012 Clinical Wk#_1
Allergies: NKDA_________________________________
Nursing Diagnosis: Problem r/t etiology Refers to specific patient problem and need. NOT A MEDICAL DIAGNOSIS
Short Term Goal
Met, Partial Met, Not Met and Analysis
Patient oriented, Realistic, Timed, and Measurable
Patient will have improved skin integrity BEOS (by end of
stay) AEB decreased redness and improved healing of stage 4
ulcer.
Goal met patient wound healing without difficulty.
If goal partial met or not met put why it was not met and
what you plan to do. Example goal not met wound healing
not improving, review and revise plan of care with patient and
team members.
Assessment Interventions
What you would assess and monitor with rationale:

Asses extremities’ for normal range of motion (limited movement can cause contractures)

Assess VS and LOC (changes in memory, orientation, etc could indicate neurological deficits: and change in VS could indicate
infection, resp./cardiac distress)
Nursing Interventions: (Specific to Patient)
Intervention with rationale
1.
Linen wrinkle –free/dry (moisture and wrinkles
increase breakdown of the skin)
Evaluation of Interventions (Patient’s Response)
Evaluations are patient oriented, not nurse oriented. There
should be a patient response to the intervention performed.

Skin remained free from further breakdown
2.
Avoid friction when moving patient (to prevent skin
breakdown)

Used draw sheet-not friction or shearing of skin
3.
Reposition every 1-2 hours; get patient out of bed.
(prolonged pressure on bony prominences decreases
circulation and increases skin breakdown)

Turned and reposition q2, no increased reddened
areas.
4.
Encourage ADLs ( to increase perfusion and
circulation)
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Patient assisted with ADLs
5.
ROM (passive and active) (increases circulation to
prevent DVTS; maintains joint mobility and
decreases development of contractures)
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FROM in bilateral arms decreased range of motion in
both legs.
Patient Education and Health Maintenance:
Teaching
1.
Referral
Instruct active ROM exercises (see NI 5 above)
1.
Evaluation: Patient demonstrated active ROM
exercises
Physical Therapy (assists with physical needs, RIM,
ambulating, equipment)
2.
Home Health (assists with needs at home, bathing,
medications, dressing change)
Interventions should be problem specific and performed interventions are to be highlighted and an evaluation done.
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Student Name: Nurse Nancy SVN
Patient Initials: JDS
Age: 86
Clinical Prep Sheet
Unit: 3-East
Date: 01/01/2012 Clinical Wk#_1
Allergies: NKDA_________________________________
Therapeutic Communication (Must submit at least one (1) conversation per week – two exchanges)
Non Verbal Behavior
Verbal Behavior
Nurse – Pulled up chair along
side of bed and leaned
forward.
“You seem upset about
something.”
Patient – Makes contact with
nurse. Shakes head yes.
“I am”
Nurse – Facing the patient.
“Tell me more about your
feelings.”
Patient – Dries tears, looks
angry.
“I’m scared and angry.”
Communication Technique
Interpretation
Evaluation
Making Observation
Therapeutic
I think the client appears
upset.
I thought I could get the
client to talk.
Ineffective – There were no
feelings of anger expressed. I
could have said, “You seem
angry.”
Open ended question
Therapeutic
I think the client is angry.
I thought I had made her
angry.
Effective – The client voices
that she is scared and angry.
Must submit one (1) communication interview per week. If you need more room you can continue on another CPS sheet.
Reflection of Clinical Week (What did you expect, what really happened? How do you think you are progressing? )
Reflect over your clinical week. Put you thoughts, experiences, and feelings. If you found a specific strength or
weakness you discovered about yourself you document here. State one thing you would have changed or done
differently.
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Student Name: Nurse Nancy SVN
Patient Initials: JDS
Age: 86
Clinical Prep Sheet
Unit: 3-East
Date: 01/01/2012 Clinical Wk#_1
Allergies: NKDA_________________________________
CPS Medication Sheet
Medication
Generic & Trade
Dosage & Route
digoxin
Lanoxin
Classification
Why is your client
taking this drug?
Cardiac
Glycoside
CHF
Loop Diuretic
CHF
0.125 mg 1xday PO
furosemide
Lasix
40mg 1xday
captopril
PO
Capoten
ACE Inhibitor
Hypertension
12.5mg every 8 hours
PO
potassium Cl
K-Dur
Electrolytes
10 mEq 2xday PO
ibuprofen
Motrin
NSAID
Electrolyte
Replacement
Muscle Pains
600mg every 6 hours
PO
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Nursing Implications
Adverse Effects
Most Serious implications
and what information you
need as a nurse to perform
or assess before giving
medication. Minimum of 3
implications.
Minimum of 3 adverse
effects.
1. Do not give if apical pulse
less than 60.
2. Monitor digoxin level;
electrolytes.
3. Monitor for violent
vomiting.
1. I&O every shift, daily
weight.
2. Monitor B/P, S/S
overload/deficit.
3. Monitor potassium level.
1. Nausea/Vomiting
2. Yellow Hazes
3. Dysrhythmias
1. Monitor B/P-do not give
if less than 90/60.
2. Monitor for orthostatic
hypotension.
3. Teach to take when BP is
within a normal range.
1. Dry cough
1. Monitor K level (>5.8).
2. Monitor high potassium
foods.
3. Store at room
temperature.
1. Muscle cramps
1. Take with food to
minimize GI distress.
2. Take around the clock
(ATC).
3. Advise to use sunscreen
to prevent photosensitivity.
1. GI Bleed
1. Hypokalemia
2. Muscle cramps
3. Decreased BP
2. Angioedema
3. Bronchospasm
2. Bradycardia
3. Confusion
2.Hepatitis
3. Increased bleeding
time
11/2012