dbott_ClinicalWorksheet_10312019.docx - Clinical II Worksheet Date Student Name_Dani Bott NUR 2571 Clinical II(use additional pages as needed Clinical

dbott_ClinicalWorksheet_10312019.docx - Clinical II...

This preview shows page 1 - 3 out of 9 pages.

Clinical II Worksheet Date: 10/28/2019________ Student Name: _Dani Bott___ NUR 2571 Clinical II (use additional pages as needed) Clinical Site Instructor: Instructor Lee_ Previous Shift Report: Karen _______________ Client Initials: F.S. Rm#:_6B Client age: 95__ Gender: F___ Height: 63”____ Weight: 213.9lb__ BMI: 37.9____ Baseline vitals: BP 152/73__ Pulse 65__ Resp. 20_____ Temp. 97.8___ Pain Score____4/10 Location: Knees Transfer Status: Independent with walker___ Allergies: NKA Code Status: _DNR____ Occupation: Farmer Religion: _____ Pastoral Care: Attends Church___________________________________ Marital Status: W Cultural Background: Caucasian _ Primary Language: English ______________ Diet/Nutrition: Regular_____ Activity: Up as tolerated______________ Fall Risk: Yes / No Use of (type/amount/frequency): Alcohol: Minimal Tobacco (pack years): No__________ Treatments: Ace Wraps on LE for edema, Aspercreme for joint pain bilateral knees IV /Tubes/Ostomies: NA Interdisciplinary Cares (OT/PT/RT) & frequency OT/PT 3x/week OT 3XWEEK__________________ Dressings/Wounds: (type & location) NA___________________________________________________________ Oxygen: (delivery method & amount) Room Air 9%____________ Dialysis: NA 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. Use wording that you would use to explain these to the client, layman terms. Make sure these are on your Systems Disorder Remediation Template. (Should be in the appropriate location). Limit these to the last 6 months, mark N/A as appropriate. Date Test Normal Value Client Value Significance 10/25/2019 BUN 7-22 39 KIDNEY COMPROMISE 10/25/19 CREATININE 0.5-1.02 1.97 KIDNEY COMPROMISE 10/25/2019 CHLORIDE 98-107 110 DEHYDRATION ______________________________________________________________ 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. Use wording that you would use to explain these to the client, layman terms. Make sure these are on your Systems Disorder Remediation Template. (Should be in the appropriate location). Limit these to the last 6 months or current stay on unit, mark N/A as appropriate. Date Time_ Normal Client’s result Significance of this 10/3/2019 CHEST CT CARDIOMEGALY ENLARGED HEART Rasmussen College- Blaine Campus M.Lee, Sept 2019 1
Image of page 1

Subscribe to view the full document.

Clinical II Worksheet Date: 10/28/2019 Client Initials: F.S. Student Name: Dani B. Clinical Site/Unit: Crestview ASSESSMENT SUMMARY: To be completed during the clinical day. Body System Subjective data-Health History Objective data—Assessment findings Vital signs and Pain level “my pain is about a 4 out of 10, my knees always hurt” Temp- 97.8 HR- 65 RR- 20 O2-93%RA BP- 152/73 Pain Score- 4/10 Sensory “Can you get my glasses for me dear?” Sensation present bilaterally- face, arms, feet to light touch. Wears glasses Neurological “I have 11 kids!! We lived in Wisconsin” Alert and orientedx3 No tremors, free movement x4 extremities Speech clear PERRLA Cooperative Respiratory Denies SOB Denies cough Lung sounds clear bilaterally-no use of accessory muscles Regular breathing O2 93%RA Cardiac
Image of page 2
Image of page 3
  • Winter '18

What students are saying

  • Left Quote Icon

    As a current student on this bumpy collegiate pathway, I stumbled upon Course Hero, where I can find study resources for nearly all my courses, get online help from tutors 24/7, and even share my old projects, papers, and lecture notes with other students.

    Student Picture

    Kiran Temple University Fox School of Business ‘17, Course Hero Intern

  • Left Quote Icon

    I cannot even describe how much Course Hero helped me this summer. It’s truly become something I can always rely on and help me. In the end, I was not only able to survive summer classes, but I was able to thrive thanks to Course Hero.

    Student Picture

    Dana University of Pennsylvania ‘17, Course Hero Intern

  • Left Quote Icon

    The ability to access any university’s resources through Course Hero proved invaluable in my case. I was behind on Tulane coursework and actually used UCLA’s materials to help me move forward and get everything together on time.

    Student Picture

    Jill Tulane University ‘16, Course Hero Intern

Ask Expert Tutors You can ask You can ask ( soon) You can ask (will expire )
Answers in as fast as 15 minutes