PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

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Student Name:

Week:

Dates of Care:

Patient Initials M.R	Sex F	Age 62	Room 616	Admitting Date 5/27/2022		Admitting Chief Complaint: What symptoms cause the patient to come to the hospital? Right knee Arthrotomy Right knee patella revision
Attending physician/Treatment team: Frisch, Nilesardo, Maya, long K Ham						Consults: Hospitalist group, Md
Present Diagnosis: (Why patient is currently in the hospital) – Left wrist pain – Right knee pain – Moderate episode of recurrent major depressive disorder (HCC) – Panic disorder with agoraphobia, mild agoraphobic avoidance, and mild panic attacks – Numbness and tingling in both hands – Mass of left wrist							ER Management: (if applicable) Total knee replacement Right knee patella revision
Allergies: Niacin and Related					Code Status: Full code			Isolation: (type and reason) None
Admission Height: 170.2 cm (5’7)					Admission Weight: 124.7 lg (275 lb)			Arm Band Location (colors & reasons)
Communication needs: (verbal, nonverbal, barriers, languages) No problem with communications. Can speak English and there were no language barriers.
Past Medical History: (pertinent & how managed) – Anxiety – Arthritis (pt states osteoarthritis) – Asthma – Depression – Diabetes mellitus (HCC) – Diabetes mellitus, type 2 (HCC) – General weakness 2 to S/P. Lt. TKR (total knee replacement) using cement – GERD (gastroesophageal reflux disease) – Hypertension – Migrains – PONV (postoperative nausea and vomiting) – Right knee pain – Stroke (HCC) TIA x2 in 2011 and 2012 with LUE weakness
Significant Events during this hospitalization but not during this clinical time: (include the date, event and outcome) A 62-year-old Hispanic female with a history as noted below presents for the elective procedure(s): The patient states did well after bilateral TKAs in 2014 but fell on R knee 2-3 months ago and has had patellar pain since that time, especially with weight-bearing, flexion, and turning Saw their care provider with concern for loosening of the prosthesis. No recent or other UTI/URI sx, chest pain, shortness of breath, orthopnea, PND, dizziness, syncope, palpitations, LE pain/swelling, fevers/chills, headaches, confusion, numbness/tingling/weakness, speech/swallowing/vision changes, back pain, abdominal pain, nausea, vomiting, diarrhea, constipation, melena/hematochezia, or COVID symptoms.

Tests/Treatments/Interventions impacting clinical day’s care (include current orders)

Assessments and interventions: (Include all pertinent data)

Vital signs: (2 sets per day)

Time	0942	1322
T	98.3	98.2
P	79	62
R	18	18
B/P	143/63	149/77

Time	1355	1425
T	98.2	98.5
P	94	88
R	18	18
B/P	154/72	170/69

GI:

Diet:

Swallow precautions:

Tube feedings:

NG / G tube:

Blood Glucose: (time & date)

Last bowel movement: (time & date)

Pertinent Labs/Test:

Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)

Respiratory:

02 modalities:

02 Saturation:

Suction:

Resp Rx’s:

Trach:

Chest Tubes:

Pertinent Labs/Test:

Assessments/Interventions: (Lung sounds, cough, sputum, SOB)

Neurosensory:

Neuro checks:

Alert & Orientated:

Follows commands:

Speech Comprehensible:

Pertinent Labs/Test:

Assessments/Interventions:

(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)

Cardiovascular:

Telemetry:

Pacemaker/IAD:

DVT Prevention:

Daily Weights:

Pertinent Labs/Test:

Assessments/Interventions:

(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)

Musculoskeletal:

Activity:

Traction:

Casts/Slings:

Pertinent Labs/Test:

Assessments/Interventions:

(strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps

Renal:

Catheter (indwelling/external):

CBI:

Dialysis:

A/V access:

Pertinent Labs/Test:

Assessments/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O)

Skin:

Braden Score:

Pertinent Labs/Test:

Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)

Pain:

Pain score:

Assessments/Interventions:

(scale used, location, duration, intensity, character, exacerbation, relief, interventions)

Vascular Access: (IV site)

Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)

Gyn:

Gravida/Para:

LMP:

Last Pap:

Breast exam:

Pertinent Labs/Test

Assessment/Interventions: (bleeding, discharge)

Post-operative /procedural:

Assessments/Interventions:

(immediate post procedure care)

Safety:

Call light:

Bed Rails:

Bed alarms:

Fall risk:

Assistive Devices:

Sitter use:

Restraints (type, duration & reason):

Assessment/Interventions (modifications to room, environment, Patient)

Advance Directives/Ethical considerations:

DPOA:

Hospice:

Pertinent Data (Labs, X-rays, Etc.)	Results	Normal Lab Values	Significance to your patient
WBC	10.0
RBC	4.20
HGB	12.4
HCT	36.4
MCV	86.7
MCH	29.5
MCHC	34.0
Platelets	12.9
RDW	198
MPV	7.3

PT	N/A
INR	N/A
APTT	N/A

Glucose	188
BUN	17
Creatinine	0.75
Sodium	138
Potassium	3.9
Cloride	103
Calcium	9.0
T Protein	N/A
Albumin	N/A
SGOT	N/A
SGPT	N/A
Alk Phos	N/A
Magnesium	N/A
Amylase	N/A
Lipase	N/A

CPK	N/A
LDH	N/A
Cholestrol	N/A
	N/A
CK	N/A
CK-MB	N/A
Troponin I	N/A
Myoglobin	N/A
LDI	N/A


Urinalysis	N/A
Color	N/A
Character	N/A
Spec. Grav.	N/A
pH	N/A
Protein	N/A
Glucose	165 (H)
Acetone	N/A
Bilirubin	N/A
Blood	N/A
Nitr	N/A
Urobili	N/A
RBC	N/A
WBC	N/A
Epithelium	N/A

Urine Culture	N/A

Chest X-ray	N/A

MRI	N/A

CT Scan	N/A

Others test:	N/A

Psycho/Social: Assessment/Interventions:(mental illness, social history, living arrangements, primary caregiver, substance abuse, maternal/infant bonding, family dynamics)

Cultural/Spiritual needs: Assessment/Interventions: (religious preference, adaptations & modifications, end of life decisions)

Growth & Development: (physical, psychosocial, cognitive, moral, spiritual using various theorist) What stage of development evident with patient:

Current overall plan of care: (A short statement that summarizes the anticipated plan of care)

Discharge plans and needs:

Teaching needs:(Disease process, medications, safety, style, barriers)

Pathophysiological Discussion: Discuss the current disease process at the cellular level (in your own words). Explain why this patient is encountering this particular health deficit. What is the relationship of this current health alteration to the patient’s other medical conditions? Describe the current disease process the patient is encountering etiology, epidemiology, pathophysical mechanism, manifestations and treatment (medical and surgical). Also note the complications that may occur with these treatments and the patient’s overall prognosis. Include appropriate references and use APA format.

Attach a research article pertaining to diagnosis of patient. Write a summary about the article.

List of nursing diagnoses (NANDA format). Place diagnoses in priority order and provide rationale for priority setting. May only list one nursing diagnosis that is a Risk For diagnosis.

Priority	Nursing Diagnosis	Related to	As Evidence By	Rationale (reason for priority)
1
2
3
4
5

Medications	Classification	Dose	Route	Freq	Purpose/Mechanism of Action	Significant Side Effects / Adverse Reactions	Nursing Implications
Morphine PF Injection		4mg	Intravenous	Every 4hrs PRN	Severe pain breakthrough pain
Aluminum & Magnesium hydroxide (Maalox plus)		15ml	Oral	Every 6hrs PRN	Indigestion
Docusate sodium (Colace) capsule		100 mg	Oral	2 times daily	Constipation
Enoxaparin (Loveriox)		40mg	Injection Subcutaner	Every 12 hr
Gabapentin (Neurontin)		300 mg	Oral	Every 8 hrs
Ibuprofen (Motrin)		600mg	Oral	Nightly PRN
Ketorolac (TORADOL) Injection		15mg	Intravenous	Every 6hrs
Oxycodone (Roxicodone)		10mg	Oral	Every 4hrs PRN	Immediate release, Severe pain
Hydroxyzine (ATARAX)		25mg	Oral	Nightly PRN	Itching, sleep

Nursing Diagnosis: Identify the top two nursing Diagnoses and expand

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)

Patient Goal(s)

Statement of purpose for the patient to achieve

Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)

(Must have at least two short term outcomes and two long term outcomes)

Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.

Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)

Nursing Diagnosis: Identify the top two nursing Diagnoses and expand

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)

Patient Goal(s)

Statement of purpose for the patient to achieve

Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)

(Must have at least two short term outcomes and two long term outcomes)

Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.

PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

Medications

Classification

Dose

Route

Purpose/Mechanism of Action

Significant Side Effects / Adverse Reactions

Nursing Implications

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)

Patient Goal(s)

Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)

Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.

Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)

Assessment as evident by (AEB) or data collection relative to the nursing diagnosis (Appropriate for chosen diagnosis. Includes objective & Subjective historical data that support actual or risk for nursing diagnosis)

Patient Goal(s)

Patient Outcome (Should be measurable, attainable, realistic and timed, all criteria should be present and specific to the patient Dx.)

Interventions/Implementations (Must have at least four nursing interventions for each outcome written that directly relate to the patient’s goal statement and help to reach the patient outcomes. They should be specific in action, frequency, and contain a rationale.

Evaluation. (Was the outcome met, partially met or not met and why? And is the plan of care revised or continued and new evaluation date/time is set)

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