EMORY UNIVERSITY
NELL HODGSON WOODRUFF SCHOOL OF NURSING
NRSG 360 – Clinical Nursing I
Clinical Work Sheet for Weekly Clinicals
OVERVIEW: (Preparation for clinical week 2)
Client’s Initials__L.W________ Age 74YRS___Admit Date_11/17/2014____ and/or Procedure Date _11/17/2014________
Today’s Date_11/20/2014________
Medical Diagnosis/Reason for Admission __Post-operative _pain____ Admitting Diagnosis: RIGHT KNEE REVISION
Describe (Brief Pathophysiology in your own words, including HPI)__Patient is a 74 years female with right knee revision due to acute post-operative pain came in for surgical consultation due to continued pain and a valgus deformity after having cast removed. She is on hinged knee brace for stability.
Allergies: Ancef, Tolectin 600, Cephalosporins
Social Hx Patient is a retired pharmacist, married with children. She is alert and oriented x4; uses tobacco before but quitted 20years ago.__________________________________________________________
HOW ARE THE ABOVE ITEMS RELATED? (Preparation – Add on by Clinical week 3)
Treatments (Accuchecks, dressing changes, PT, OT, RT, activity order, diet, Isolation, I/O)
Medications (See Medication Summary)
Systematic & Concise Summary of Physical Assessment findings (See Checklist for Routine Bedside Assessment)
General: (includes vital signs) BP: 119/69, P: 93, T: 73.3, R: 18, SaO2: 95, Pain: 8/10
Neuro: Alert and oriented x4, Pupils dilated and face expression is symmetry.
Cardiac: Clear on S1 and S2. No extra heart sounds, murmurs, or ribs.
Respiratory: Breathing is unlabored, chest movement is symmetric.
Integumentary: (include wounds) Skin is normal, warm and moist, no skin discoloration. Wound dressing on the right knee and right femur edema.
GI: Normal bowel sounds hyperactive in all quadrants.
GU: Clear yellow urine
Musculoskeletal: Active range of motion on upper extremities, impaired range of motion on lower extremities with brace on right leg. Right foot is dissented.
Safety Concerns Fall risk, Pressure sore risk.
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
DIAGNOSIS: *Radiology results; lab; micro; orders
Pertinent Diagnostic Tests This includes abnormal and significant normal.
|
Test |
Date |
Findings/Results |
Implications/Nursing care |
|
X-RAY knee 1or 2 view right |
11/17/2014 |
Degeneration joint disease |
Revision of the tibia and femoral |
|
X-ray chest 1or 2 view |
11/12/2014 |
Cardiomegaly, Tortuous descending aorta, left basilar atelectasis. |
Surgery |
Lab Tests with Rationale for Abnormals and Implication of Findings:
|
Name of lab |
Reference Range |
Level at Admit |
Level on Last Lab |
Nursing Implications
|
||
|
Date |
Level |
Date |
Level |
|||
|
Red blood cell count |
3.93- 5.22mmol/L |
11/17/2014 |
2.8210E6/mcl |
11/20/2014 |
2.6410E6/mcl |
Due to Surgery |
|
Hemoglobin |
11.4-14.4 mmol/L |
11/17/2014 |
7.9gm/dl |
11/20/2014 |
7.4gm/dl |
Due to Surgery |
|
Hematocrit |
33.3-41.4 mEq/L |
11/17/2014 |
25.0% |
11/20/2014 |
24.4% |
Due to Surgery |
|
mEq/L |
||||||
|
mg/dL |
Nursing Plan of Care
Nursing Plan of Care
|
NANDA NURSING DIAGNOSTIC LABEL (Choose #1 priority problem for patient) |
RELATED FACTORS Secondary to a Disease or Condition |
DEFINING CHARACTERISTICS* (As evidenced by signs or symptoms) * Remember “Risk For” Diagnoses do not yet have defining characteristics! |
|
Acute pain |
Related to knee replacement surgery |
Subjective: As evidence by pain rate of 10/10 Objective: Lower extremity weakness. |
Nursing Diagnosis Statement: Acute Pain______________________________________________
|
PATIENT EXPECTED OUTCOMES/GOALS (Specific, Measurable, Achievable, Realistic, Timely) |
PLANNED NURSING INTERVENTIONS & RATIONALE |
EVALUATION (Not Met, Partially Met or Met) |
|
Patient Goal Patient will indicate pain level decrease to less than 5/10 |
Your Intervention: Administer pain medication |
Evaluation of Goal Goal partially met, Patient pain level was managed to a level of 6/10. |
|
Your Intervention: Facilitate Rest Your Intervention: Provide relaxation and guided imagery. |
Nursing Plan of Care
Nursing Diagnosis Statement_____Ineffective coping ______________________________________________
|
NANDA NURSING DIAGNOSTIC LABEL (Choose #1 priority problem for patient) |
RELATED FACTORS Secondary to a Disease or Condition |
DEFINING CHARACTERISTICS* (As evidenced by signs or symptoms) |
|
Ineffective coping |
Related to pain due to ineffective function |
Subjective: patient report of anxiety Objective: patient appears withdrawn |
|
PATIENT EXPECTED OUTCOMES/GOALS (Specific, Measurable, Achievable, Realistic, Timely) |
PLANNED NURSING INTERVENTIONS & RATIONALE |
EVALUATION (Not Met, Partially Met or Met) In patient terms only, summarize response to intervention |
|
Patient Goal (may have several) Patient will learn two coping skills |
Your Intervention: Encourage family support |
Evaluation of Goal Goal met, patient was able to relax by listening to , and daughter was there to give a moral support |
|
Your Intervention: Administer antidepressant /antianxiety medication Your Intervention: Involve relaxation therapy |
Nursing Plan of Care
Nursing Diagnosis Statement: Risk for ineffective peripheral tissue perfusion.
|
NANDA NURSING DIAGNOSTIC LABEL (Choose #1 priority problem for patient) |
RELATED FACTORS Secondary to a Disease or Condition |
DEFINING CHARACTERISTICS* (As evidenced by signs or symptoms) |
|
Risk for ineffective peripheral tissue perfusion. |
Related to coagulating factors released by bone during surgery. |
Subjective: Objective: |
|
PATIENT EXPECTED OUTCOMES/GOALS (Specific, Measurable, Achievable, Realistic, Timely) |
PLANNED NURSING INTERVENTIONS & RATIONALE |
EVALUATION (Not Met, Partially Met or Met) In patient terms only, summarize response to intervention |
|
Patient Goal (may have several) Prevent clotting |
Your Intervention: Give anticoagulant medication |
Evaluation of Goal Goal met, |
|
Your Intervention: Encourage ambulation Your Intervention: Give compression stockings |
Nursing Plan of Care
Nursing Diagnosis Statement: Risk for fall _________________________________________________
|
NANDA NURSING DIAGNOSTIC LABEL (Choose #1 priority problem for patient) |
RELATED FACTORS Secondary to a Disease or Condition |
DEFINING CHARACTERISTICS* (As evidenced by signs or symptoms) |
|
Risk for fall |
Related to lower extremity weakness |
Subjective: Objective: |
|
PATIENT EXPECTED OUTCOMES/GOALS (Specific, Measurable, Achievable, Realistic, Timely) |
PLANNED NURSING INTERVENTIONS & RATIONALE |
EVALUATION (Not Met, Partially Met or Met) In patient terms only, summarize response to intervention |
|
Patient Goal (may have several) Prevent patient from falling |
Your Intervention: Assist with ambulation |
Evaluation of Goal Met, patient was able to ambulate to bedside Commode. |
|
Your Intervention: Make sure bed is in low position with the rails at the top of the bed up Your Intervention: Involve physical therapy |
References for your entire clinical worksheet:
Ruth F. Craven, Constance J. Hirnle, Sharon Jensen, (2013) Fundamental of nursing: human health and function,
(7th Ed). Philadelphia, PA: Lippincott Williams & Wilkins Inc.
Gulianick, M. and Myers, J. (2003). Nursing Care Plans: Nursing Diagnosis and Interventions. Mosby: St Louis
Pearson Education http://wps.prenhall.com/
Nursing Central (200-2014) Using web sources in writing, Retrieved from http://www.unboundmedicine.com/
Schedule: *Pt Care Summary; Med list; Pt schedule; task list
|
7am |
Visit with patient and getting report from night shift staff. |
|
8am |
Perform vital signs |
|
9am |
Giving medication |
|
10am |
Assist with morning care, mouth care, assist with bath. |
|
11am |
Head to toe Assessment |
|
12pm |
Assist to bathroom, Accu-check. |
State1 personal learning goal for this clinical day: ________Be able to give IV push and make my patient more comfortable. _________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Did you meet your personal goal for the day?
_____________________________________________Goal Met, I was able to give IV push of 5% dextrose to my patient after noticing low level of glucose. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Checklist for Routine Bedside Nursing Assessment
|
Mental/Neuro Status
|
Cardiopulmonary
|
|
Vital Signs
|
Gastrointestinal
|
|
Genitourinary
(Assistive devices)
|
|
|
Motor Sensory Function
|
Wound
|
|
Integumentary
|
Invasive Tubes (IV’s, NGT, Wound drains, Catheters, etc..)
|
Modified by Erin Poe Ferranti, 2005, 2007; Corrine Abraham, 2007
Adapted From: Elkin, Potter & Perry (2004) Nursing Interventions & Clinical Skills (3rd ed.) Mosby: St. Louis
Medications MAR; MAR Summary: Medication Profile*
|
Medication: Name/Dose/Route |
Time |
Classification |
Purpose |
Side Effects/Nursing Considerations |
|
OxyCODONE(10mg=1tab) 1 tablet PO |
9:00 am |
Opioid analgesics |
Reduce pain |
Respiratory Depression May cause drowsiness |
|
Exenatide (10mcg injection) 1 each BID |
PRN |
Antidiabetics |
Lower blood sugar |
Pancreatitis, weakness |
|
Insulin aspart (BG > 150) (BG -100) /40= unit |
Antidiabetics |
Lower blood sugar |
Anaphylaxis, hypoglycemia |
|
|
Atorvastin (liptor) 20mg=1 tab, 1 tablet PO |
9:00 am |
Antilipidemia |
Reduce Cholesterol level |
Chest pain, Rhabdomyolysis |
|
BuPRion 300mg=1tab 1tablet PO |
9:00 am |
Antidepressant |
Treatment for depression |
Seizure, anxiety, dry mouth, depression |
|
ClonazePAM (0.5mg=1tab) 1mg=2tablets PO |
9:00 am |
Anticonvulsant |
Prevention of seizure |
Fatigue, constipation, suicidal thought |
|
Docusate sodium (100mg=1cap) 1capsule PO |
9:00 am |
laxative |
Prevent constipation |
Mild cramps, diarrhea, rashes |
|
Enoxaparin 30mg =0.3ml subq |
9:00 am |
anticoagulant |
Blood thinner |
Constipation, urinary retention |
|
Levothyroxine (25mcg=1tab) 1tablet PO |
7:00 am |
hormonal |
Treatment for hypothyroidism |
Tachycardia. Abdominal cramps |
|
Alprazolam (0.25mg=1tab) |
9:00 am |
antianxiety |
Relief of anxiety |
Constipation, blurred vision |
|
Venlafaxine (75mg=1cap )150mg= 2capsule |
PRN |
Antidepressant antianxiety |
Decrease depression, anxiety and panic attack |
Chest pain, anorexia, itching, epistaxis |
|
Hydrocodone (10mg-1tab) 1tablet PO |
9:00 am |
opioid |
Decrease pain |
Respiratory depression, apnea, anaphylaxis |
Cite This Work
To export a reference to this article please select a referencing style below:
