Download - Clinical WorkSheet - Template
RNSG 1262 Nursing Case Study
Student Name: _________________________________________ Dates of Care: _______________________Client Initials: ________ Gender: _____ Age: ____ RM# _____ Med Team/MD: ___________________Admitting Diagnosis: _______________________________________________ Date of Admission: __________________Concurrent Diagnoses: ___________________________________ Surgery: ________________________ Date: ______________Allergies to Drugs or Foods: _____________________ Advanced Directives / Code Status: ______________
Therapeutic Modalities/ MD Orders:
Data Collection Day Clinical Day 1 Clinical Day 2
Vital Signs/SpO2: Frequency
I & O/ Fluid Restrictions
Diet
Scheduled Diagnostics
Activity Level
Dressing Change Orders
Resp. Therapy
Physical Therapy
Daily Weights
SCD, TEDS, CPM
Accuchecks
Daily Labs:
Other Treatments:
Summaries of Progress Notes:
Doctor’s Data Collection Day
Doctor’s Data Collection Day #1
and or Day #2
Nurse’sData collection Day
Nurse’sData Collection Day #1
and/or Day #2
Pathophysiology of Admitting Diagnosis:
Pathophysiology of Concurrent Diagnoses:
Description of Surgical Procedures:
Lab Data Sheet - highlight abnormals
Labs/X-rays/Dx Tests Results
Normal Range
Date Result
DateResult
DateResult
Correlation to Pathophysiology: Interpret results as well as correlating with the client’s medical condition:
Complete Blood Count: WBC 3.6-11.0
RBC 4.5-5.90Hg 13.5-17.5Hct 41-53Platelets 150-450
ESR N/A
Differential
Other:
MCV 30-98MCH 26-34MCHC 31-37RDW 12.0-14.6Mean Platelet 6.8-10.2
Chemistry: Na 135-145
K 3.5-5.1
Cl 94-106
Glucose 60-100
Total Protein 6.2-8.1
Albumin 3.5-5.0
CO2 20-29
BUN 7-25
Cr 0.7-1.60
Calcium 8.2-10.3
Other:Bilirubin Total 0.2-1.2
Bilirubin Direct 0.0-0.4
ALT 0-35
AST 0-38
Mg 1.6-2.2
Phos 2.4-4.6
Alk Phos 32-108
Lactic Acid (Plasma)
0.5-2.2
Anion Gap 5-19
Coagulation Studies: INR 0.8-1.2
PT 22-37
PTT
Urinalysis:
Clarity ------Color -----Bilirubin Negative
Blood Negative
Glucose Negative
Ketones Negative
Leukocytes Negative
pH 5-8Protein NegativeSp Gravity 1.001-
1.035Urobilonogin 0-1mg/dL
Microscopic:WBC 0-5 HPFRBC 0-5 HPFEpithelial 0-5 HPFBacteria 0-450
HPFCasts 0-1
UDS
Amphetamine Negative
Barbituate Negative
Benzodiazapine Negative
Cannabinoids Negative
Opiates Negative
PCP Negative
Cocaine Negative
Arterial Blood Gases:pH 7.35-7.45PCO2 32-48PO2 83-108O2 sat -----
HCO3 21.0-28.0
Culture & Sensitivity:note source/growth and sensitivity
Exudate Culture -------Gram Stain --------
Fungal Calcaflour --------
Radiological Studies:
X-Ray - Chest
Sonogram Extremity
CAT Angiograph
EKG:
Diagnostic Tests: describe results
Vancomycin Level
------
Blood Antibody ScreenImmunology
Hep B- Antigen Non Reactive
Hep B- Antibody Non Reactive
Hep A Non Reactive
Hep C Non Reactive
Trade Name Pharmacological Class Dose/Route Rationale for this client Major Side Effects Nursing Implications for Safe Administration and
Evaluation of Therapeutic Effects
Generic Name Mechanism of Action Max Dose
Trade Name Pharmacological Class Dose/Route Rationale for this client Major Side Effects Nursing Implications for Safe Administration and
Evaluation of Therapeutic Effects
Generic Name Mechanism of Action Max Dose
Trade Name Pharmacological Class Dose/Route Rationale for this client Major Side Effects Nursing Implications for Safe Administration and
Evaluation of Therapeutic Effects
Generic Name Mechanism of Action Max Dose
Trade Name Pharmacological Class Dose/Route Rationale for this client Major Side Effects Nursing Implications for Safe Administration and
Evaluation of Therapeutic Effects
Generic Name Mechanism of Action Max Dose
Trade Name Pharmacological Class Dose/Route Rationale for this client Major Side Effects Nursing Implications for Safe Administration and
Evaluation of Therapeutic Effects
Generic Name Mechanism of Action Max Dose
Trade Name Pharmacological Class Dose/Route Rationale for this client Major Side Effects Nursing Implications for Safe Administration and
Evaluation of Therapeutic Effects
Generic Name Mechanism of Action Max Dose
Physical Assessment - Data Collection Day
Neurosensory
Level of Consciousness: Alert: Oriented: Confused: Lethargic: Unresponsive: to Verbal stimuli Y N Painful Stimuli: Y NGlasgow /coma Scale Rating (if needed) ______Disoriented: Person Place TimeBehavior: _________________________
Communication/Speech Pattern: ______________
Pupil size: Rt. ______ Lt. ______Reaction: __________Vision Impairment: Y N
Describe: ___________________________________ Glasses: Y N
Sensation: Intact LossesDescribe:___________________________________
Hearing loss: : Y N Describe:___________________________________
History or current alterations affecting this system:Sedative medications
Possible Nursing Dx:
Musculoskeletal
Motor Strength: 0 = complete paralysis, 1= flicker of movement, 2 = overcome gravity, 3 = 50% of normal4= 75 % of normal strength, 5= 100% of normal strengthRUE ____ LUE ____ RLL ____ LLE ____
Describe:__________________________
Mobility: _______________________________________________________________________
ROM - L= Limited
Activity/ Restrictions: ____________________________________________________________________
Risk for Fall: : Y N
Use of Assistive Devices: ____________________________________________________________________________________________________________________
History or current alterations affecting this system:
Possible Nursing Dx:
Respiratory
Respiratory Rate: ____Pattern: _____ Normal _____ Shallow _____ Rapid_____ Labored_____Cough: Non –Productive ___ Productive ___ Describe:______________________________________________________________________________
Chest inspection (expansion, deformities): _______________________________________________________________________________________________
Use of accessory muscles: yes ___ no: __ Lung Sounds: 1 = clear, 2 = diminished, 3 = crackles, 4 = rhonchi, 5 = wheezing, 6 = friction rub.
RUL ___ RML __ RLL _____ LUL ___ LLL_____
O2 saturation: Room Air:___ ______ On Oxygen Therapy:________
History or current alterations affecting this system:
Possible Nursing Dx:
Cardiovascular:
Apical pulse: ____Rhythm: regular irregular Heart Sounds: Aortic _____Pulmonic ______ Tricuspid _____Mitral ______ Describe abnormalities: _________________________________________________________________
Capillary Refill: < 3sec > 3 sec.
Pulses: describe as 0 = absent, 1 = doppler, 2 = weak, 3 = normal and 4 = bounding
___RR __LR ____RDP ___LDP ___ RPT ___LPT
Dialysis Shunt: : Y N Condition: __________________________________________________
Homan’s sign: ____ Positive ____ Negative N/A
Edema: describe as 0=none, 1+= barely detectable, 2+ indentation, 3+ indentation, 4+ indentation = > 10mm
RUE ____ LUE ____ LLE ____ RLE _____ Periorbital_____ Sacral______
JVD: : Y N
History or current alterations affecting this system:
Possible Nursing Dx:
Gastrointestinal
Abdomen: distended non-distended Bowel Sounds: describe as A = absent, N = normal, HA= hyperactive, HO= hypoactive___ RUQ ___RLQ ___LUQ ____LLQ
Last BM: __4/10/11___(date)diarrhea _____ constipation ____ normal__x___
Ostomy: Y NType/describe fistula: _________________________ __________________________________________
N/G decompression: : Y N Describe: ______________________________________________________________________________________Feeding tube/PEG: : Y NFeeding type/rate: ____________________________Patency/Residual:____________________________
History or current alterations affecting this system:
Possible Nursing Dx:
Genitourinary
Patterns: continent ___ incontinent ___ nocturia___ ___ frequency ___ urgency ___ dysuria _____ urinary retention ___
Appearance: clear ___ cloudy ___yellow ___ pink ___ amber ____bloody____
Catheter: : Y NType-____________________________________
24 hour I&O______________________________
History or current alterations affecting this system:
Possible Nursing Dx:
Integument
Temp: ___warm, ___hot, ___coolMoisture: ___dry, ___moist, ___diaphoreticColor: ___normal, ___ pale, ___ cyanotic, ___ flushed ___Other (describe)______________________________Skin Condition:_____normal_____________________________________________________________
Incision/wounds:(describe)___________________________________________________________________________________________________________
Dressing Orders:____________________________________________________________________________________________________________________
Braden Scale Score: _____PUSH Tool Score: __________
History or current alterations affecting this system:
Possible Nursing Dx:
Nutrition
Adm. Weight: ________Current Weight:_______Ideal Body Weight:____History of Weight loss: ___________________________________________________________________
Diet History: ___ ___________________________________________________________________________________________________________
Appetite:____ _________________________
Percent of meal eaten: Breakfast:________Lunch:_________ Dinner: _________Snacks:_____________________________________
Describe condition of teeth/denture/oral mucosa: _________________________________________________________________________________________________________________________________Other: _____________________________________
Blood glucose monitoring: Reading/time ______________ Reading/time_____________
History or current alterations affecting this system:
Possible Nursing Dx:
Pain Assessment (describe)
Type of Pain: Acute______ Chronic____
Location: ________________________
Intensity/Rating:_____________________________
Pattern: ____________________________________
Nature : _______________________________________________________________________________________________________________________________________________
History or current alterations affecting this system:
Possible Nursing Dx:
List all scheduled, prn, and IV medications
Physical Assessment - Data Collection Day of Care# 1 Vital Signs:__________________________
Neurosensory
History or current alterations affecting this system:
Possible Nursing Dx:
Musculoskeletal
History or current alterations affecting this system:
Possible Nursing Dx:
Respiratory
History or current alterations affecting this system:
Possible Nursing Dx:
Cardiovascular:
History or current alterations affecting this system:
Possible Nursing Dx:
Gastrointestinal
History or current alterations affecting this system:
Possible Nursing Dx:
Genitourinary
History or current alterations affecting this system:
Possible Nursing Dx:
Integument
History or current alterations affecting this system:
Possible Nursing Dx:
Nutrition
History or current alterations affecting this system:
Possible Nursing Dx:
Pain Assessment:(describe)
History or current alterations affecting this system:
Possible Nursing Dx:
Wound / Surgical Incision Assessment:Assessment Wound #1 Wound #2 Wound #3Type of woundand StageLocation
Length
Width
Depth
Drainage
Odor
Undermining / TunnelingWound bed tissue type
Factors affecting wound healing:
Miscellaneous Information:
Physical Assessment - Data Collection Day of Care# 2 Vital Signs:___________________________
Neurosensory
History or current alterations affecting this system:
Possible Nursing Dx:
Musculoskeletal
History or current alterations affecting this system:
Possible Nursing Dx:
Respiratory
History or current alterations affecting this system:
Possible Nursing Dx:
Cardiovascular:
History or current alterations affecting this system:
Possible Nursing Dx:
Gastrointestinal
History or current alterations affecting this system:
Possible Nursing Dx:
Genitourinary
History or current alterations affecting this system:
Possible Nursing Dx:
Integument
History or current alterations affecting this system:
Possible Nursing Dx:
Nutrition
History or current alterations affecting this system:
Possible Nursing Dx:
Pain Assessment:(describe)
History or current alterations affecting this system:
Possible Nursing Dx:
Wound / Surgical Incision Assessment: Document changes for day two.Assessment Wound #1 Wound #2 Wound #3Type of woundand StageLocation
Length
Width
Depth
Drainage
Odor
Undermining / TunnelingWound bed tissue type
Factors affecting wound healing:
Miscellaneous Information:
Assessment Data: Psychosocial/ Cultural
Stressors: Behaviors/Coping Strategies
Identified culture/ethnicity Religion Occupation Family Role
Developmental Task:Clients Developmental Task According to Erikson: Describe if the client has/has not achieved their developmental task. Include positive/negative resolution and justify your conclusion.
Psychosocial Diagnosis:
Understanding of Illness/Treatments
Community Referral
Nursing Dx Priority_1__Hospital Outcome/Goal: Nursing Interventions:
Designate I: independent D: dependent C: collaborative/interdependent
Scientific Rationale Evaluation(Specify as goal met/unmet/or partially met)
Nursing Diagnosis/Analysis:
Correlation to Patho or Psycho-physiology
Discharge Goal: Teaching Plan:
Nursing Dx Priority___ Hospital Outcome/Goal: Nursing Interventions:Designate I: independent D: dependent C: collaborative/interdependent
Scientific Rationale Evaluation(Specify as goal met/unmet/or partially met)
Nursing Diagnosis/Analysis:
.
Correlation to Patho or Psycho-physiology
Discharge Goal: Teaching Plan:
Nursing Dx Priority____ Hospital Outcome/Goal: Nursing Interventions:Designate I: independent D: dependent C: collaborative/interdependent
Scientific Rationale Evaluation(Specify as goal met/unmet/or partially met)
Nursing Diagnosis/Analysis:
Correlation to Patho or Psycho-physiology
Discharge Goal: Teaching Plan:
Nursing Dx Priority____ Hospital Outcome/Goal: Nursing Interventions:Designate I: independent D: dependent C: collaborative/interdependent
Scientific Rationale Evaluation(Specify as goal met/unmet/or partially met)
Nursing Diagnosis/Analysis:
Correlation to Patho or Psycho-physiology
Discharge Goal: Teaching Plan:.