Download Mr. Practice pre clinical research Sp17

Name: ____________________________
Clinical # ____________
Date: _____________
PATHOPHYSIOLOGY RESEARCH FORM
Medical Diagnosis ______________________________________ Is this an Acute or Chronic Illness? _______________
Pathophysiology
Signs/Symptoms and
Complications
Briefly describe the Diagnosis in your own words.
Identify short-term signs and symptoms.
Identify short-term complications.
Identify long-term complications or disabilities.
Nursing Assessment and
Interventions
Identify specific areas that are important to assess on this patient.
Identify tasks/procedures you will need to perform on this patient.
Where will you focus education on for this patient?
Medical Orders/Treatment
Identify laboratory tests that should be ordered for this diagnosis.
Identify diagnostic tests that should be ordered for this diagnosis.
Identify procedures associated with this diagnosis.
Identify medications that should be ordered with this diagnosis.
Sources in APA Format:
SURGICAL PROCEDURE RESEARCH FORM
Name of surgery or invasive procedure performed on your client: _________________________________________
Surgery/Procedure
Briefly describe the surgery/procedure in your own words.
What is the anticipated outcome of this surgery/procedure?
What complications should you anticipate?
Pre-Procedure
Identify specific areas to assess on this patient pre-procedure.
What do you need to teach your patient prior to the procedure?
Post-Procedure
Identify specific areas to assess on this patient post-procedure.
What do you need to teach your patient after their procedure?
Sources in APA Format:
Medication Research Form
Research the medications on your client’s current medication administration record. Include PRN (as needed) medications only if
they have been given within the past 24 hours or if you anticipate your client will receive them on clinical day.
Drug Name &
Classification
Therapeutic Outcome
intended for your client
Lasix (Furosemide)
Treat fluid overload for
heart failure by
decreasing circulating
volume
Loop diuretic
Albuterol
Aminophylline
Ceftin
Insulin NPH & Reg
KDur
Lanoxin
Mechanism of Action
for Therapeutic Use
Works early in the
nephron
List 3 major adverse reactions
and related nursing
interventions
1. Orthostatic hypotension—
check patient’s blood
pressure prior to
administration.
2. Potential fall risk—
complete fall risk
assessment and institute
appropriate fall risk
precautions
3. Electrolyte imbalance—
monitor labs Na, K
List any lab values or vital signs
to assess prior to
administration. Include the
normal or expected value.
1. K (N3.5-5.0)—Notify
physician and consider holding
medication if the value is below
this range especially if no
supplemental K is administered.
2. Na (N135-145)—monitor for
neuro changes (altered LOC,
HA) if value is below range,
notify physician
3. BP —assess BP prior to
administration. Consider holding
if SBP <110
Lovenox
Norco
Tenormin
Sources in APA Format
LAB DATA
Lab or Diagnostic Test
Normal Value
Date
Date
Date
Discuss how the lab values reflects this patient’s health status and response to
treatment. Link the lab values to the patient’s treatment or condition.
CBC
Chemistry
Digoxin level
Aminophylline level
Sources in APA Format
Diagnostic Tests
Diagnostic
Tests
Date of Test
X-RAY
EKG
Culture
Sources in APA Format
Results or Impression
Relate to your patient-link the diagnostic test result to the patient.
Head to Toe Assessment
Area
What do you need to Assess? Include medical
devices.
Overall/Head/Neuro Assess LOC
Assess Orientation
Are they in any distress?
Assess Pain scale c symptom analysis, any
methods to relieve pain.
What position are they in?
Mood?
Overall skin?
Assess pupils for size, light reflex,
accommodation.
Oxygen device, type, LPM.
Assess Oral cavity: teeth, mucus membranes.
Is speech clear?
Face symmetrical?
Any visual or hearing impairments?
Assess Vital Signs.
Posterior Thorax
Anterior Thorax
Heart
Abdomen
GU
How would you chart the information assessed?
A&A, Ox3, In NAD at present. Rates pain 5/10, states
cramping to lower back, began 5 mins ago, no relief c
position change, or diversion. Sitting upright in bed @
60Ο angle. Smiling. Skin W/D c even color distribution.
Pupils PERRLA. O2 @ 2L NC. Teeth intact, mucous
membranes moist. Speech clear. Facial features
symmetrical. T 98.5, P 88, R 14, BP 124/76.
Upper Extremities
Lower Extremities
Safety
Treatment Flow Sheet
Directions: In the columns below, list any treatments, procedure, or medical equipment related to your client's care. Then describe the
nursing care, including assessment and appropriate documentation. Do not repeat entries on items correctly documented on a previous
clinical week.
Treatment, Procedure or Medical
Equipment
Oxygen-NC
Primary IV
Saline lock
Glucometer checks (POC glucose)
List of Supplies Needed
Nursing Assessment/Actions
Documentation
Sequential Compression Device
(SCD)
TED Hose
PO meds
Metered dose Inhaler
SQ injection
Neuroascular checks
Sources in APA Format
IV Therapy
IV Fluids
Ml/hr
Gtts/min
Location
Primary IV Therapy
Cath ga Dosage calculation (show work)
NS
Total flds
(5 hrs)
ml/hr
gtts/min
Saline lock
Drug
Dose
Aminophylline
IV Fld
Amt flds
Mg/ml
IVPB
Dosage calculation (show work)
ml/hr
gtts/min
Ceftin
ml/hr
gtts/min
Sources in APA Format
Updated Sp16
Total flds
(5 hrs)