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Patient history: The patient  has history of traumatic brain injury secondary to motor vehicle accident and with cognitive and physical deficits spasticity  / hemiplegia of left side of the body .

Admission diagnosis: altered mental status.

Discharge diagnosis summary: AMS / possible acute toxic encephalopathy, and SIRs.

Ola was 40yrs he presented to the hospital with Altered mental status, he was lethargic and not following commands in hospital. She was admitted for AMS (altered mental status) .he was Keppra loaded as she appeared post-ictal . placed on seizure precaution with neuro checks overnight in the ICU and he improved and was transferred to floor. His mentation continued clear. Blood cultured drawn 12-22 returned positive for staph epidermidis times 2 -> most likely contaminant. He did meet SIRS( Systemic Inflammatory Response Syndrome) criteria with CBC < 4 and heart rate > 90, although upon review of his medical record his leukocytosis is chronic. he was given dose of vancomycin and BCx redrawn with NGTD -> ID evaluated patient and antibiotic were deescalated . TSH elevated normal T4.


Date:

________

Student Name:

____________________________

Clinical Site/Unit: ___________________________


Clinical Site Instructor:__ ____________________________Previous Shift Report:

____________________________


Client Initials:

_______

Client age:

_______

Gender:

_____________

Height:

__________

Weight:

______________


Allergies:

______vicodin __________________________

Code Status: _________________ Transfer Status: ______________


Marital Status:

_____________

Religion:

_________________

Occupation:

___________________________________


Cultural Background:

____________________________

Primary Language:

_______________________________


Diet/Nutrition:

____________________________

Activity:

_______________________________

Fall Risk:

Yes / No


Use of (type/amount/frequency): Alcohol:

_____________

Tobacco (pack years):

______________________________


Medical Diagnosis(s):


Admitting Diagnoses to Acute Care Facility

1._____altered mental status _______________________________ 2.______________________________________


Primary Diagnoses for Admission to TCU/LTC

1._____acute toxin encephalopathy ________________________________ 2.____ Systemic Inflammatory Response Syndrome_________________________________

3._____sepsis ______________________________4.______stap.epidermis _______________________________


Secondary Diagnoses

1.____chronic pain __________________________________ 2._______ _____________________________

3.________traumatic brain injury _______________________________ 4._confusion__________________________________


Surgical History

1.______________________________________ 2.___________________________________

3._______________________________________ 4.___________________________________


Treatments:

_______________________________

IV/Tubes/Ostomies:

______________________________________


Dressings/Wounds: (type & location)

___________________________________________________________________


Oxygen: (delivery method & amount)

_______________________________

Dialysis:

___________________________


Recent 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.



Date




Test


Normal Value


Client Value


Significance

Wbc           4-10                    4.1 ________________________________________________________________________________________________________________________________RBC                    3.80 -5.40            4.95 ____________________________________________________________hematocrict 35.0- 47.0            37.5

Mcv           80-100                76

______________________________________________________

MCH  2                 7-34 –                                                     22

___________________________________________________________________________________________________

PLT

___________________________________________238________________________________________________________


Recent 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. ____________________________________________________________________________________________________________________


PATHOPHYSIOLOGY:

For the primary admitting diagnosis to the acute care facility and primary diagnosis for the TCU/LTC, provide a 3-5 sentence explanation of the pathophysiology of the problem. Then complete an ATI template for the above four diagnoses (4 total).

Use the “Active Learning Template: Systems Disorder” template from ATI Active Learning templates.  Complete, print, and attached to paperwork


PATHOPHYSIOLOGY CONTINUED:

For the top two secondary diagnoses, write a 1-2 sentence explanation of pathophysiology of the diagnosis and explain how this secondary diagnosis may impact your client’s condition during this hospitalization.

If your client is post-surgical, what problems or complications could possibly occur? What nursing assessments would you need to include in your post-operative or post-procedure monitoring


PATHOPHYSIOLOGY CONTINUED:

4 secondary diagnoses, write a 1-2 sentence explanation of pathophysiology of the diagnosis and explain how this secondary diagnosis may impact your client’s condition during this hospitalization.


Medication


(Include dose, time, route, & frequency)


Classification


What nursing considerations should


you include with this medications


?


Buspar  15mg


Baclofen 20mg


Cymbalta 30mg


Levetiracetam 1000mg


Omeprazole 20mg


Robafen 100mg /5ml


Senna 8.6mg


Tizanidine hcl 2mg


Xarelto 20mg


Oxycodone HCL 5mg


ibuprofen


Medication Data Sheet


List all scheduled medications for your shift


Drug Name and Classification, Normal Adult Dose, Route & Schedule


Indications for Use and Expected Actions


Side Effects/ Adverse Reactions


Drug and Food Interactions


Nursing Administration Considerations


Client education &


Evaluation of Medication Effectiveness

Ticagrelor

Atorvastin

Pantoprazole

HumLIN  insulin regular

Diclofenac


NURSING PROCESS

Write 2 complete Nursing Diagnoses based on your client problems you noted on your assessment for this day.


Nursing Diagnosis #1:


___________________________________________________________________________________________________

Client Goal:

________________________________________________________________________________________

List 2 priority nursing interventions related to this diagnosis with the rationale for each intervention.

1.

_______________________________________________________________________________________________

Rationale:

_________________________________________________________________________________________

Outcome Assessment:

________________________________________________________________________________

2:

_________________________________________________________________________________________________

Rationale:

_________________________________________________________________________________________

Outcome Assessment:

________________________________________________________________________________


Nursing Diagnosis #2:


__________________________________________________________________________________________________

Client Goal:

________________________________________________________________________________________

List 2 priority nursing interventions related to this diagnosis with the rationale for each intervention.

1.

______________________________________________________________________________________________

Rationale:

_________________________________________________________________________________________

Outcome Assessment:

________________________________________________________________________________

2.

________________________________________________________________________________________________

Rationale:

________________________________________________________________________________________

Outcome Assessment:

________________________________________________________________________________


Post-Clinical Education:

Provide the group with education on a topic you learned about preparing for your client/clinical packet.  For example a medical diagnosis, intervention, medication, lab value, treatment method, etc.  Use this space to write your speaking notes and reference(s).

Patient history: The patient has history of traumatic brain injury secondary to motor vehicle accident and with cognitive and physical deficits spasticity / hemiplegia of left side of the body . A
Lola nur 400 Patient history: The patient has history of traumatic brain injury secondary to motor vehicle accident and with cognitive and physical deficits spasticity / hemiplegia of left side of the body . Admission diagnosis: altered mental status. Discharge diagnosis summary: AMS / possible acute toxic encephalopathy, and SIRs. Ola was 40yrs he presented to the hospital with Altered mental status, he was lethargic and not following commands in hospital. She was admitted for AMS (altered mental status) .he was Keppra loaded as she appeared post-ictal . placed on seizure precaution with neuro checks overnight in the ICU and he improved and was transferred to floor. His mentation continued clear. Blood cultured drawn 12-22 returned positive for staph epidermidis times 2 -> most likely contaminant. He did meet SIRS( Systemic Inflammatory Response Syndrome) criteria with CBC < 4 and heart rate > 90, although upon review of his medical record his leukocytosis is chronic. he was given dose of vancomycin and BCx redrawn with NGTD -> ID evaluated patient and antibiotic were deescalated . TSH elevated normal T4. Date: ________ Student Name: ____________________________ Clinical Site/Unit: ___________________________ Clinical Site Instructor:__ ____________________________Previous Shift Report: ____________________________ Client Initials: _______ Client age: _______ Gender: _____________ Height: __________ Weight: ______________ Allergies: ______vicodin __________________________ Code Status: _________________ Transfer Status: ______________ Marital Status: _____________ Religion: _________________ Occupation: ___________________________________ Cultural Background: ____________________________ Primary Language: _______________________________ Diet/Nutrition: ____________________________ Activity: _______________________________ Fall Risk: Yes / No Use of (type/amount/frequency): Alcohol: _____________ Tobacco (pack years): ______________________________ Medical Diagnosis(s): Admitting Diagnoses to Acute Care Facility 1._____altered mental status _______________________________ 2.______________________________________ Primary Diagnoses for Admission to TCU/LTC 1._____acute toxin encephalopathy ________________________________ 2.____ Systemic Inflammatory Response Syndrome_________________________________ 3._____sepsis ______________________________4.______stap.epidermis _______________________________ Secondary Diagnoses 1.____chronic pain __________________________________ 2._______ _____________________________ 3.________traumatic brain injury _______________________________ 4._confusion__________________________________ Surgical History 1.______________________________________ 2.___________________________________ 3._______________________________________ 4.___________________________________ Treatments: _______________________________ IV/Tubes/Ostomies: ______________________________________ Dressings/Wounds: (type & location) ___________________________________________________________________ Oxygen: (delivery method & amount) _______________________________ Dialysis: ___________________________ Recent 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. Date Test Normal Value Client Value Significance Wbc 4-10 4.1 ________________________________________________________________________________________________________________________________RBC 3.80 -5.40 4.95 ____________________________________________________________hematocrict 35.0- 47.0 37.5 Mcv 80-100 76 ______________________________________________________ MCH 2 7-34 – 22 ___________________________________________________________________________________________________ PLT ___________________________________________238________________________________________________________ Recent 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. ____________________________________________________________________________________________________________________ PATHOPHYSIOLOGY: For the primary admitting diagnosis to the acute care facility and primary diagnosis for the TCU/LTC, provide a 3-5 sentence explanation of the pathophysiology of the problem. Then complete an ATI template for the above four diagnoses (4 total). Use the “Active Learning Template: Systems Disorder” template from ATI Active Learning templates. Complete, print, and attached to paperwork PATHOPHYSIOLOGY CONTINUED: For the top two secondary diagnoses, write a 1-2 sentence explanation of pathophysiology of the diagnosis and explain how this secondary diagnosis may impact your client’s condition during this hospitalization. If your client is post-surgical, what problems or complications could possibly occur? What nursing assessments would you need to include in your post-operative or post-procedure monitoring PATHOPHYSIOLOGY CONTINUED: 4 secondary diagnoses, write a 1-2 sentence explanation of pathophysiology of the diagnosis and explain how this secondary diagnosis may impact your client’s condition during this hospitalization. Medication (Include dose, time, route, & frequency) Classification What nursing considerations should you include with this medications? Buspar 15mg Baclofen 20mg Cymbalta 30mg Levetiracetam 1000mg Omeprazole 20mg Robafen 100mg /5ml Senna 8.6mg Tizanidine hcl 2mg Xarelto 20mg Oxycodone HCL 5mg ibuprofen Medication Data Sheet List all scheduled medications for your shift Drug Name and Classification, Normal Adult Dose, Route & Schedule Indications for Use and Expected Actions Side Effects/ Adverse Reactions Drug and Food Interactions Nursing Administration Considerations Client education & Evaluation of Medication Effectiveness Ticagrelor Atorvastin Pantoprazole HumLIN insulin regular Diclofenac NURSING PROCESS Write 2 complete Nursing Diagnoses based on your client problems you noted on your assessment for this day. Nursing Diagnosis #1: ___________________________________________________________________________________________________ Client Goal: ________________________________________________________________________________________ List 2 priority nursing interventions related to this diagnosis with the rationale for each intervention. _______________________________________________________________________________________________ Rationale: _________________________________________________________________________________________ Outcome Assessment: ________________________________________________________________________________ 2: _________________________________________________________________________________________________ Rationale: _________________________________________________________________________________________ Outcome Assessment: ________________________________________________________________________________ Nursing Diagnosis #2: __________________________________________________________________________________________________ Client Goal: ________________________________________________________________________________________ List 2 priority nursing interventions related to this diagnosis with the rationale for each intervention. ______________________________________________________________________________________________ Rationale: _________________________________________________________________________________________ Outcome Assessment: ________________________________________________________________________________ 2. ________________________________________________________________________________________________ Rationale: ________________________________________________________________________________________ Outcome Assessment: ________________________________________________________________________________ Post-Clinical Education: Provide the group with education on a topic you learned about preparing for your client/clinical packet. For example a medical diagnosis, intervention, medication, lab value, treatment method, etc. Use this space to write your speaking notes and reference(s). Ola was 40yrs he presented to the hospital with Altered mental status , he was lethargic and not following commands in hospital. She was admitted for AMS ( altered mental status) .he was Keppra loaded as she appeared post-ictal . placed on seizure precaution with neuro checks overnight in the icu and he improved and was transferred to floor. His mentation continued clear. Blood cultured drawn 12-22 returned positive for staph epidermidis times 2 -> most likely contaminant. He did meet SIRS criteria with CBC < 4 and heart rate > 90 , although upon review of his medical record his leukocytosis is chronic . he was given dose of vancomycin and BCx redrawn with NGTD -> ID evaluated patient and antibiotic were deescalated . TSH elevated normal T4. The pt has history of traumatic brain injury secondary to motor vechicle accident and with cognitive and physical deficits spasticity / hemiplegia of left side of the body 8