Care guide 2 2 17 2 - ..... PDF

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Nursing Clinical Care Guide Date: 2/2/17 Student: Assigned Nurse: Andy PCA: __________ MD: Patient Initials: JS Room #: 5-1 Age: 78 M Height: _______ Weight: _______ Code Status: Full Allergies: Penicillin’s, Shellfish, Tetracycline, Doxycycline, Sulfamethoxazole, trimethoprim, iodinated contrast media, tiotropium bromide Precautions: Contact Adm Date: 1/27/17 Reason for Admission: VRE Primary Diagnosis: UTI, Pyelonephritis Acute on chronic anemia Past Medical History: Anemia, HTN, COPD, 02 dependent 4 liters, APPY. Bladder CA with radiation in March 2012, Sciatica Psoriasis, Bursitis, Bilat cataract surg Past Surgical History: 1/27 IR replaced L nephrostomy tube Report from previous shift or co-assigned RN: Came from Meadows, 02 dependent 4 liters, UTI & pyelonephritis, chronic anemia, being discharged to vibrant, foley out 300 ml no hematuria, CBC pending, coccyx pink intact and blanchable Collaborative interventions from Kardex or new orders: (VS, IV, O2, activity, diet, safety, FSBS, lab specimens needed, OT, PT, Consults) T: 98.7, P: 85, RR: 16, BP: 138/77, 02: 95% 4L Pain: 4 Dysphagia- puree w thin liquids Meds with applesauce CBC pending, contact precaution, Amb as tolerated Primary Medical Diagnosis (or other diagnosis as directed by instructor): explain in your own words. Kidney infection is inflammation of the kidney from bacteria and urinary tract infection is any part of the kidneys, bladder, or urethra Your patient: Text book research for this medical diagnosis: Cause/etiology: caused by the bacterium Escherichia coli (E. coli), usually found in the digestive system Signs and symptoms: A burning feeling when you urinate A frequent or intense urge to urinate, even though little comes out when you do Pain or pressure in your back or lower abdomen Cloudy, dark, bloody, or strange-smelling urine Feeling tired or shaky Fever or chills (a sign the infection may have reached your kidneys) Medical/Surgical Interventions: Antibiotics

Cause/etiology for your patient: Bacterial infection, urinary catheter

Nursing Interventions: Emphasize importance of keep area clean and dry Encourage fluid intake

Nursing Interventions implemented: Perineal care done Patient output 300 ml

Diagnostic Testing or lab work for this diagnosis: Urine sample, MRI, CT, ultrasound

Diagnostic testing or lab work done: (explain on next page) Urine sample

MY, KR Revised January 2016

Signs and symptoms exhibited/experienced: Cloudy, bloody urine Tired Chills

Medical/Surgical Interventions ordered: IV antibiotics

Discharge Planning/teaching for this diagnosis: Long term needs and who is responsible for actions to be taken Available resources and specific referrals made Individual equipment needs and source

Patient Assessment:

Your patient’s discharge planning/teaching for this diagnosis: Verbalized understanding of condition Manage care of urinary catheter

Subjective & Objective assessment findings Day 1

Vital signs: (take (2) sets of VS per shift unless otherwise directed

Discharged

Neurological

A&0 x3, cooperative, wears eye glasses Memory intact Cough reflexes intact Cardiovascular

Positive pulses, Cap refill good Denies chest pain No edema

Respiratory

LS top lobes clear bottom LS wheezing Productive cough 4L o2 Smoking hx Mucus membranes pink

Skin

Warm dry intact 3 lidocaine patches on back Coccyx pink intact and blanch able

Musculoskeletal

Weak Fall risk

GU

Foley draining brown with hematuria Left nephrostomy tube draining clear Yellow

GI

Day 2

Mouth moist, Abd soft non distended BS active Last BM 3 days prior No N/V/D Anemia Use of laxatives MY, KR Revised January 2016

Pertinent Laboratory and Diagnostic test data: (Include abnormal values and other significant normal values based on current problems, meds and patient history) Lab or Diagnostic Normal Results Results Explanation/Rationale (Why are values high/low/or On Admission Latest findings significant for this patient/trending patterns) test(s) Range (Date)

(Date)

Creatine Kinase

24-204

13

Low associated with muscle weakness, low protein diet

Sodium

134-144

141

WNL

Potassium

3.6-5.6

4.2

WNL

Chloride

96-109

96

WNL

Co2

20-32

37

High due to COPD

BUN

5-26

10

WNL

Glucose

65-99

110

High infection, too many carbs, ill, stress, inactive

Calcium

8.3-10

8.6

WNL

Developmental Assessment: According to Erikson, state the developmental level you perceive your patient to be functioning at and substantiate your assessment. If applicable, explain how current illness affects the stage of development. Older adult- deals with the loss of eating normal foods due to dysphagia, being able to take care of himself. Loss of living at home rather than a nursing home/rehabilitation

MY, KR Revised January 2016

Quinsigamond Community College Medication Sheet Medication (Identify Generic, Trade Names & Dose Ordered) Write in complete order/dose

Normal (Adult) Dose Range, Safe Dose? Y  N 

Generic Name: Trade Name: INVanz Dose: 1 GM IV___

Safe Dose? Y  N 

Generic Name: Trade Name: Duoneb Dose: 3 ML neb____

Safe Dose? Y  N 

Generic Name: Trade Name: Senokot Dose: 17.2 mg PO daily

Safe Dose? Y  N 

Generic Name: Trade Name: Prilosec Dose: 20 mg PO BID MY, KR Revised January 2016

Safe Dose? Y  N 

Classification (s) A drug can have more than one classification

Therapeutic Action(s) (How does it work)

Indications/Purpose (Why is this patient receiving it)

Nursing Considerations / Major Side Effects and/or any BLACK BOX WARNINGS

Medication (Identify Generic, Trade Names & Dose Ordered) Write in complete order/dose

Normal (Adult) Dose Range, Safe Dose? Y  N 

Generic Name: Trade Name: Tylenol Dose: 1,000 mg PO q8h

Safe Dose? Y  N 

Generic Name: Trade Name: Floranex Dose: 1 EA PO BID

Safe Dose? Y  N 

Generic Name: Trade Name: Zofran Dose: 4 mg IV Q8H prn

Safe Dose? Y  N 

Generic Name: Trade Name: Morphine Dose: 2 mg IV Q3H PRN

MY, KR Revised January 2016

Safe Dose? Y  N 

Classification (s) A drug can have more than one classification

Therapeutic Action(s) (How does it work)

Indications/Purpose (Why is this patient receiving it)

Nursing Considerations / Major Side Effects and/or any BLACK BOX WARNINGS

Interventions:

Rationales:

Assessment Data (related to this Nursing diagnosis)

S:

O:

#1 prioritized Nursing diagnosis (2 or 3 part)

DX:

R/T:

AEB:

EXPECTED OUTCOME

MY, KR Revised January 2016

Evaluation (of Expected Outcome)

Interventions:

Rationales:

Assessment Data (related to this Nursing diagnosis)

S:

O:

#2 prioritized Nursing diagnosis (2 or 3 part)

DX:

R/T:

AEB:

EXPECTED OUTCOME

MY, KR Revised January 2016

Evaluation (of Expected Outcome)

Documentation:

Write a focused nursing note.

Focus: Note:

PNP 200 Self-Assessment of Clinical Performance Student Comments What did you learn this week? Describe your learning by relating it to a specific clinical behavior from the clinical evaluation tool. (Discuss 3 examples and begin the comment with the number of the clinical behavior.) 1.

Personal/Professional

II. Safety III. Communication IV. Critical Thinking V. Teaching

What do you feel positive about from clinical this week? What would you do differently?

Special requests:

MY, KR Revised January 2016

Faculty Comments...