Patient history: The patient has history of traumatic brain injury secondary to motor vehicle accident and with cognitive and physical deficits spasticity / hemiplegia of left side of the body.
Admission diagnosis: altered mental status.
Discharge diagnosis summary: AMS / possible acute toxic encephalopathy, and SIRs.
Ola was 40yrs he presented to the hospital with Altered mental status, he was lethargic and not following commands in hospital. She was admitted for AMS (altered mental status) .he was Keppra loaded as she appeared post-ictal . placed on seizure precaution with neuro checks overnight in the ICU and he improved and was transferred to floor. His mentation continued clear. Blood cultured drawn 12-22 returned positive for staph epidermidis times 2 -> most likely contaminant. He did meet SIRS(Systemic Inflammatory Response Syndrome) criteria with CBC < 4 and heart rate > 90, although upon review of his medical record his leukocytosis is chronic. he was given dose of vancomycin and BCx redrawn with NGTD -> ID evaluated patient and antibiotic were deescalated. TSH elevated normal T4.
Date: ________ Student Name: ____________________________ Clinical Site/Unit: ___________________________
Clinical Site Instructor:__ ____________________________Previous Shift Report:____________________________
Client Initials: _______ Client age: _______ Gender: _____________ Height: __________ Weight:______________
Allergies: ________________________________ Code Status: _________________ Transfer Status: ______________
Marital Status: _____________ Religion: _________________ Occupation:___________________________________
Cultural Background: ____________________________ Primary Language:_______________________________
Diet/Nutrition: ____________________________ Activity: _______________________________ Fall Risk: Yes / No
Use of (type/amount/frequency): Alcohol: _____________ Tobacco (pack years):______________________________
Medical Diagnosis(s):
Admitting Diagnoses to Acute Care Facility
1.____________________________________ 2.______________________________________
Primary Diagnoses for Admission to TCU/LTC
1._____________________________________ 2._____________________________________
3._____________________________________4._____________________________________
Secondary Diagnoses
1.______________________________________ 2.____________________________________
3._______________________________________ 4.___________________________________
Surgical History 1.______________________________________ 2.___________________________________
3._______________________________________ 4.___________________________________
Treatments: _______________________________ IV/Tubes/Ostomies:______________________________________
Dressings/Wounds: (type & location)___________________________________________________________________
Oxygen: (delivery method & amount) _______________________________ Dialysis:___________________________
Recent LAB Results:
Why is this lab significant for this client’s condition? If the lab result was abnormal, include what the NURSE needs to monitor for or do related to the abnormal lab result under the significance column.
Date Test Normal Value Client Value Significance
_____WBC _ 4.0—11.0 4.1 ________________________________________________________________ RBC 3.80 -5.40 4.95 ____________________________________________________________HEM_ 35.0 -47.0 37.5 _____________________________________________________________ MCV 80-100 76 __
MCH 7-34 22
_PLT 238
HEMOGLOBIN 12-16 11.1 __________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Recent Diagnostic tests: (list X-rays, CT scans, MRIs, ECGs, Ultrasounds, Cardiac Catheterizations, etc.)
List the test, the test result, and include an explanation of the significance of the results in relation to the medical treatment, other diagnostics, and nursing considerations/interventions for your client. _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________________________________________________
PATHOPHYSIOLOGY:
For the primary admitting diagnosis to the acute care facility and primary diagnosis for the TCU/LTC, provide a 3-5 sentence explanation of the pathophysiology of the problem. Then complete an ATI template for the above two diagnoses (2 total). Use the “Active Learning Template: Systems Disorder” template from ATI Active Learning templates. Complete, print, and attached to paperwork.
PATHOPHYSIOLOGY CONTINUED:
For the top two secondary diagnoses, write a 1-2 sentence explanation of pathophysiology of the diagnosis and explain how this secondary diagnosis may impact your client’s condition during this hospitalization.
If your client is post-surgical, what problems or complications could possibly occur? What nursing assessments would you need to include in your post-operative or post-procedure monitoring
To be completed the day of clinical
Vital Signs
Pain: Pain is normal for him due to his TBI 8 out of 10
Neurological: The patient oriented times 4, his speech is clear and appropriate and slow .Head: No rashes , no lesion and symmetrical round. Pupils: PERRLA. Ears: no drainage, no lesion and hearing intact. Nose: clean, no drainage. Throat: moist intact, No JVD, no difficulty in swallowing, no lumps. Mouth: oral mucosa is pink and moist, no gum bleeding.
Cardiac Rate 88. Radial pulse: 2+ bilaterally equal. Chest pain: no chest pain. Peripheral Pulses: palpable present in all extremities. Edema: no edema.
Capillary refill: less than l second on finger and toes.
Respiratory: Respiration: even and relaxed. Respiratory rate: 16. Lung sounds: Breath sounds clear no crackles and wheezing. Cough : no cough . SOB: No.
Gastrointestinal: Abdomen: round and soft. Bowel sound: active times 4. Nausea and vomiting: not present. Pain: no pain upon palpation. Last BM: This morning, usually once a day . Continent: continent.
Genitourinary: Urination: Q 2h . color: clear. Dysuria: no pain. Continent: continent.
Integument: dry, no bruising, no broken. Color: appropriate for color. Wounds/ location: no wound. Dressing /location: no dressing. Upper extremities/ lower extremities: warm and moist, no bruises and wound on top of toes , between the toes and heel.
Musculoskeletal: Strength of upper extremities: strong on left arm but the right arm is flaccid. Strength of lower extremities: strong on left leg but not right leg. Weakness: yes, paralysis on right side of the body due TBI . Assist with transfers: yes, Hoyer devices use to transfer from bed to wheel chair. Assistive device: wheel chair
BP_________ HR _________ RR _________ Temp ________ O2 Sat _______% RA/LPM ________
Pain is normal for him due to his TBI
PRN Medications List
Medication
(Include dose, time, route, & frequency)
Classification
What nursing considerations should
you include with this medications?
Buspar 15mg
Baclofen 20mg
Cymbalta 30mg
Levetiracetam 1000mg
Omeprazole 20mg
Robafen 100mg /5ml
Senna 8.6mg
Tizanidine hcl 2mg
Xarelto 20mg
Oxycodone HCL 5mg
ibuprofen
Medication Data Sheet
List all scheduled medications for your shift
Drug Name and Classification, Normal Adult Dose, Route & Schedule
Indications for Use and Expected Actions
Side Effects/ Adverse Reactions
Drug and Food Interactions
Nursing Administration Considerations
Client education &
Evaluation of Medication Effectiveness
Ticagrelor
Atorvastin
Pantoprazole
Gabapentin 300mg(Neurontin).
Venlafaxine 75mg ( Effexor)
.
NURSING PROCESS
Write 2 complete Nursing Diagnoses based on your client problems you noted on your assessment for this day.
Nursing Diagnosis #1:
___________________________________________________________________________________________________
Client Goal: ________________________________________________________________________________________
List 2 priority nursing interventions related to this diagnosis with the rationale for each intervention.
1. _______________________________________________________________________________________________
Rationale: _________________________________________________________________________________________
Outcome Assessment: ________________________________________________________________________________
2: _________________________________________________________________________________________________
Rationale: _________________________________________________________________________________________
Outcome Assessment: ________________________________________________________________________________
Nursing Diagnosis #2:
__________________________________________________________________________________________________
Client Goal: ________________________________________________________________________________________
List 2 priority nursing interventions related to this diagnosis with the rationale for each intervention.
1. ______________________________________________________________________________________________
Rationale: _________________________________________________________________________________________
Outcome Assessment: ________________________________________________________________________________
2. ________________________________________________________________________________________________
Rationale: ________________________________________________________________________________________
Outcome Assessment: ________________________________________________________________________________
Documentation by exception of head to toe assessment:
SBAR communication:
S:
B:
A:
R:
Notes:
Student self-evaluation of clinical performance:
Please describe any procedures/skills you performed/ observed during the clinical experience. Also, include your assessment of how well the day went.
Post-Clinical Education:
Provide the group with education on a topic you learned about preparing for your client/clinical packet. For example a medical diagnosis, intervention, medication, lab value, treatment method, etc. Use this space to write your speaking notes and reference(s).
