Catherine Owens

Date: ________ Student Name: _______________________ Clinical Site:____________________________________

Clinical Site Instructor:___________________________________ __________________________________________

Room #_405_________Client Initials: ____SR___ ____Client age: ____52 years_______ Gender: ___Male_______

Allergies: Diphenhydramine______________________________ Code Status: ___Full code______________ ________________

Diet/Nutrition: _________Regular___________________ Activity: _______________________________ Fall Risk: Yes / No Yes (High fall risk)

Use of (type/amount/frequency): Alcohol: ___________________ Tobacco (pack years): ________________________

Treatments: _______________________________ IV/Tubes/Ostomies: ______________________________________

Dressings/Wounds: (type & location) _Shoulder-healing, Back-Tegaderm and clear absorbent.__________________________________________________________________

Oxygen: (delivery method & amount) ____N/A___________________________ Dialysis: ______N/A_____________________

LAB RESULTS: (minimum of 2 labs) Why is this lab significant for this client’s condition? Write down ABNORMAL lab results and include what the NURSE needs to monitor for or do related to the abnormal lab result under the significance column. ONLY USE ABNORMAL LAB RESULTS QSEN: Informatics, Safety SLO: 3, 8

Date Test Normal Value Client Value Significance

7/24 Sodium____135-145_ 132

7/25 Hemoglobin 14-18 9.4 __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

LABS

Look at the 2 labs you looked up for this week. For each of the labs look up what body system or system(s) it tells you about, what does an elevated level mean, and what does a low level mean. Also, are there any special considerations or client education regarding prepping the client for the test? (example: fasting for 6 hours, etc.) QSEN: Informatics, Safety SLO: 3, 8

Lab Test#1: __Sodium 135-145_______________Systems affects: ______________________________________________

Elevated level: _____________________________________________________________________________

Low level: _132___________________________________________________________________________

Lab Test #2: _Hemoglobin 14-18_________________Systems affects: ______________________________________________

Elevated level: _____________________________________________________________________________

Low level: 9.4_______________________________________________________________________________

Date: ____________ Client Initials: _SR_____ Student Name: _______________________________________________

Medical Diagnosis(s): (found in paper chart)

Admitting/Primary: Motor Vehicle Accident

____________________________________ ______________________________________

Medical History (includes medical and surgical)

Acute post hemorrhagic anemia _____________________________________

Alcohol abuse ___________________________________ _____________

PTSD____________________________________

Adjustment disorder with other symptoms___________________________________ ____

Traumatic ischemia of muscle__________________________________ ______________________________________

__________________________________ ______________________________________

____________________________________ ______________________________________

End of Shift Report or SBAR: QSEN: Informatics, Team-Work Collaboration SLO: 3

DATE

TIME

Date: ____________ Client Initials: ______ Student Name: ________________________________________________

PRN Medication List (found in paper chart) QSEN: Safety, Evidence Based Practice. SLO: 2, 4

Medication

(Include dose, time, route, & Frequency)

Classification

Indication for use

OxyCODONE (Immediate release) 5mg tablet-10mg PO

Ibuprofen 400mg tablet PO q6h

Medication Data Sheet

Date: ____________ Client Initials: ______ Student Name: ___________________________________________________

(Scheduled medications to be given to your client during your clinical shift) QSEN: Safety, Evidence Based Practice. SLO: 2, 4

Drug Name, Dose, Route & schedule

Drug Classification, Expected action & indication for use

Side Effects/ Adverse Reactions

(List 3-5)

Medication/Food Interactions

(List 3-5)

Nursing Administration Considerations & Assessments

(List 3-5)

Client education & Evaluation of Medication Effectiveness

(List 3-5)

Mirtazapine 7.5mg PO at HS

Nicotine 21mg/24hr Patch Transdermal

Gabapentin 100mg capsule PO

Methocarbamol 500mg tablet-1000mg PO

Enoxaparin 40mg/0.4ml injection 40mg subcutaneous

Melatonin 3mg tablet PO at HS

Date: ____________ Client Initials: ______ Student Name: ________________________________________________

Patient________________________ Room:__________ Hallway:_____________

Nurse: ____________________________ NA: _________________________

Temp

Oral/Tympanic

Regular/ Irregular

Laying/Sitting/Standing Right/left

Resp.

O2 %

Room Air/ Oxygen _____L

Pain

Location: Description:

Pain Intervention:

Edema:

Location:__________________ Degree:________________ pitting/non-pitting

Lung sounds:

Right_______________________ Left_________________________

Cough?_____________________ SOB?__________________________

Bowel Sounds_________________________________________

Date of Last BM______________

Trach:

Times Suctioned: Type of Trach suction: In-Line / Sterile

Vent Settings:

RR TV HA LA PEEP Mode

LMV Sensitivity Insp Time FiO2 O2 L

Keep O2 above %

Treatments Done?

Foot care Done?

PATHOPHYSIOLOGY: For each diagnosis below, provide a 3-5 sentence explanation of the pathophysiology of the problem. (**we count sentences**) QSEN: Evidence Based Practice, Informatics, Client Centered Care. SLO: 1, 2, 4

1. Primary Diagnosis: Open displaced fracture of pelvis

(3-5 sentences)

Treatments: (3 minimum)

Potential complications: (3 minimum)