Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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)