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
HR
Regular/ Irregular
BP
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)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
2. Diagnosis: Alcohol dependence with withdrawal
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
3. Diagnosis: Closed fracture of multiple ribs of left side
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
4. Diagnosis: Closed fracture of transverse process of lumber vertebra
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
5. Diagnosis: Acute blood loss anemia
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
6. Diagnosis: Respiratory failure
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
7. Diagnosis: Acute pain due to trauma
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
8. Diagnosis: Transection of urethra
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
Student 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.
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Catherine Owens 19303959
/in Uncategorized /by developerYou are called to the room and find Michael 2 hours old has been very irritable and spitting up large amounts of formula. He is very jittery. You do not know the maternal history before coming into the room so you advise the mother that you would like to return the baby to the nursery for an assessment and monitoring. In the medical record you focus on prenatal history. You witness the baby having some significant tremors. What would you suspect? Michaels VS are: T (axillary) – 36.0, RR- 70, HR- 166, he is very alert, irritable, and does not console easily. Is moving constantly, and sucking very vigorous on the pacifier you provide for comfort. You place the baby under the warmer and obtain what labs?
It is determined that this baby is going through opioid withdrawal. Neonatal Abstinence Syndrome requires close observation and scoring. Methadone may be used. Neonatal Abstinence Syndrome Shows both the signs of withdrawal, scoring and the nursing care of a baby with Neonatal Abstinence Syndrome.
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Catherine Owens 19309703
/in Uncategorized /by developerTina is 5 years old, lives with her mother and grandmother. Mother works 2 jobs to help support her mother and her daughter. Tina is well cared for but is now admitted for a cardiac catheterization due to the Ventricular Septal Defect (VSD) that was noted at birth.
Tina has an extensive history of respiratory infections and a nursing diagnosis of ‘activity intolerance’. Her mother relates that she does not allow her to play organized or competitive games due to her health. Tina smiles broadly when you come in the room to begin the pre-operative checklist. She starts to ask you a question when her grandmother tells her she must stay in the bed. “The nurse knows what she is doing and you will just be in the way.” Tina continues to smile at you but moves back to the bed.
You have identified some unique family dynamics, please relate.
What is the Erikson developmental level that Tina should exhibit? And where do you think she is?
How can you assist in the developmental growth?
What education can you give to Tina and her grandmother pre operatively?
What will she expect post operatively?
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Catherine Owens 19313707
/in Uncategorized /by developerRobert and Jenna Smith’s 2nd child has Down Syndrome. Philip is 14 years old. He has a sibling that is older and one younger. 15 year old sister, Lucy and a little brother Danny who is 10 years old. As all 14 year olds he is becoming more interested in his sexuality and expressing that with curiosity. He has been known to have some overt aggression toward his sister and some classmates in his public school.
Will this behavior interfere with his interest in being in the local Boy Scout troop? His troop leader is his father.
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Catherine Owens 19313727
/in Uncategorized /by developerTicket to Simulation
Student Name _____________________________________ Date _______________________
Diagnosis Gestational diabetes
Pathophysiology (this is not a definition-try to find out what is happening in the tissue/cells/body)
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Textbook Signs and Symptoms
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Recommended Treatments (be specific if possible, don’t just say medications, say beta blockers, ACE inhibitors, etc.)
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Teaching (what topics of patient education are important for this disease process. For example: for diabetes, weight control, diabetic diet, etc.)
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Prevention (what could have been done to prevent the patient from developing this disease process, if possible)
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Make sure to cite your sources.
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Catherine Owens 19314289
/in Uncategorized /by developerType 1 vs Type 2 Diabetes and patient education.
Discuss from scholarly journal.
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Catherine Owens 19315775
/in Uncategorized /by developerClient Profile
Ms. Champlin is a 52 – year old woman who was cooking New England clam cakes in a skillet filled with hot oil. While she was dropping the dough in the skillet, oil splattered onto the gas stove, catching on fire and filling the skillet with flames. In a panic, Ms. Champlin grabbed the handle of the burning skillet to remove it from the stove, spilling the hot oil all over her right arm and hand. The oil also splashed onto the right side of her face and neck and across her chest, burning her skin through her T-shirt. She is transported to the emergency department by emergency medical technician(EMTs).
Case Study
Upon arrival at the hospital, she is alert and oriented, without signs or symptoms of respiratory distress. She is screaming in pain. MS. Champlin’s vital signs are BP 130/60, Pulse 94, Respiratory rate 22, and Temperature 97°F (36.1°C). Her oxygen saturation is 99% on 2 Liters of oxygen. She has suffered superficial and superficial partial-thickness burns on her face, neck, and chest, and deep partial-thickness burns over her right arm and hand. The right side of her face and neck and her chest are red with several blisters noted. Her right arm and hand are swollen and have sloughing skin with a mottled appearance of cherry red, tan, and pale areas. The health care provider (HCP) does not observe any discoloration of soot around Ms. Champlin’s nose or mouth, singed nasal hair, or burned eyebrows. Acute care in the emergency department include oxygen, intravenous (IV) fluids, the insertion of an indwelling urinary catheter, nasogastric tube attached to low wall suction and the administration of IV morphine sulfate and tetanus toxoid. Ms. Champlin is transferred to a burn unit for continued care.
Questions
1. Describe each of the five types of burn injury and provide examples of each. Which type of burn has Ms. Champlin sustained?
2. Describe the appropriate first aid intervention the EMTs will initiate while en route to the hospital.
3. Using the “Rule of Nines” estimate the extent of the client’s burn injury.
4. Why did the HCP assess Ms. Champlin for discoloration around her nose and mouth singed nasal hair, and burned eyebrows? What other related manifestations should be assessed to determine if there is a need for concern?
5. In the emergency department, treatment of the client included the insertion of an indwelling urinary catheter, insertion of nasogastric (NG) tube, and administration of tetanus toxoid. Provide a brief rationale for each of these interventions.
6. Briefly describe the skin depth and manifestation that define each degree of burn injury (first-, second-, third-, and fourth-degree). What degree(s) of burn injury does Ms. Champlin have?
7. Ms. Champlin cries to the nurse, “It seems as if my arm is getting bigger by the minute! Can’t you do something?” Help the nurse explain to the client what is causing the edema and the expected progression and resolution of the swelling.
8. Ms. Champlin weighs 180 lbs. Using the Parkland Formula below, estimate the IV fluid replacement needs of this client in the first 24 hours following her injury.
Parkland Formula: 2 to 4 ml of solution
x body weight (in kg)
x percent burn
9. Help the nurse identify five priority nursing diagnosis for Ms. Champlin’s plan of care during the acute phase of her treatment.
10. The HCP is concerned that Ms. Champlin may develop a contracture of her right arm because of the burn injury over her right elbow. Discuss what a contracture is and why this client is at increas4d risk of developing one.
11. The HCP carting for Ms. Champlin tells her that I may become necessary to apply a skin graft to the deep partial-thickness area over her elbow to speed healing and minimize the risk for contracture. Skin grafts are obtained from various sources. Briefly explain these four types of grafts: autograft, allograft, heterograft, synthetic skin substitute graft. Is there any benefit(s) to selectin one type of graft over another? If so, explain.
12. Briefly discuss why environmental temperature control is an important intervention while caring for the client with a burn injury. At what temperature should the nurse maintain the client’s room?
13. Ms. Champlin has asked the nurses that no visitors be allowed in to see her. Briefly discuss Ms. Champlin’s psychological reaction to her burn. How should the nurse respond?
14. Ms. Champlin is being discharged. She will wear a custom molded hand and arm splint at home. Briefly describe the teaching points the nurse should address regarding limb assessment and proper use of the splint.
15. Ms. Champlin asks the nurse, “I have heard there is a cream you can apply to decrease scarring.” What types of cream might Ms. Champlin be referencing?
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Catherine Owens 19316771
/in Uncategorized /by developerDate: ________ 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
HR
Regular/ Irregular
BP
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)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
2. Diagnosis: Alcohol dependence with withdrawal
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
3. Diagnosis: Closed fracture of multiple ribs of left side
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
4. Diagnosis: Closed fracture of transverse process of lumber vertebra
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
5. Diagnosis: Acute blood loss anemia
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
6. Diagnosis: Respiratory failure
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
7. Diagnosis: Acute pain due to trauma
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
8. Diagnosis: Transection of urethra
(3-5 sentences)
Treatments: (3 minimum)
Potential complications: (3 minimum)
Potential Nursing Diagnosis (2 minimum)
Potential Nursing Interventions: (2 minimum)
Student 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.
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Catherine Owens 19320355
/in Uncategorized /by developerIt is 10 pm and you make assessment rounds and find Bobby crying. You ask him what his pain level is. What pain scale are you using?
He says he misses his family and wonders when they are going to come to get him and take him home? He relates his dad told him to be brave but he couldn’t stay with him since
Bobby was going to be in the hospital for such a long time and his dad had to work. He has 2 other brothers older than him. You also notice that his tray is untouched.
In addition to Erikson’s theory of development, children have fear of loss. What is Bobby’s fear?
(do not forget the interdisciplinary team members)
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Catherine Owens 19320365
/in Uncategorized /by developerDue to a fall from a second story townhouse, Jimmy sustained a fractured left femur and a mild head injury. Jimmy is 10 years old. He was reaching for a ball that had gotten lodged into the gutter over the small balcony of his parent’s bedroom. He thought if he stood on the railing and reached with the badminton racket he could get it.
Currently he is 2 days postoperative from repair of the left femur. He is being transferred out of the pediatric ICU where the Neurologist has stated he is stable but needs continued neuro checks q2 hours. He has a full left leg cast. The Foley catheter is to be replaced today, or he can attempt to roll onto a bedpan if needed.
Please list the systems that are affected by this boy’s injuries.
List the nursing interventions now that he is on your nursing unit.
Start a list of nursing diagnosis match the system you are presenting.
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Catherine Owens 19321115
/in Uncategorized /by developerIt is 10 pm and you make assessment rounds and find Bobby crying. You ask him what his pain level is. What pain scale are you using?
He says he misses his family and wonders when they are going to come to get him and take him home? He relates his dad told him to be brave but he couldn’t stay with him since
Bobby was going to be in the hospital for such a long time and his dad had to work. He has 2 other brothers older than him. You also notice that his tray is untouched.
In addition to Erikson’s theory of development, children have fear of loss. What is Bobby’s fear?
(do not forget the interdisciplinary team members)
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