Download Document 8945372

NAME: ___________________________________ COURSE: ______________
CLINICAL DATE(S) ________________________
METROPOLITAN COMMUNITY COLLEGE
Prelab/Critical Thinking Tool
To be completed for EACH assigned patient.
Client’s Initials _______ Sex ___ Age ______ Marital Status __________ Religion __________
Occupation _________________________ Allergies _________________ Room # __________
Erikson’s Psychosocial Stage _____________________________________________________
Developmental Task ____________________________________________________
Physician(s) ___________________________________________________________________
List specialty ( if numerous assigned physicians)
Chief Complaint ________________________________________________________________
Primary Diagnosis ___________________________ Secondary Diagnosis _________________
Past Medical History ____________________________________________________________
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Textbook description of the client’s condition.
(Include signs/symptoms and pathophysiology)
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Signs/symptoms noted on arrival to the hospital.
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Metropolitan Community College
Diagnostic tests R/T the signs/symptoms or manifestations of client’s condition.
Refer to the table on Page3
Medications R/T the signs/symptoms or manifestations of client’s condition.
Refer to the table on Page 4&5
Other medical treatments/interventions R/T client’s condition.
Include surgical procedures (define each procedure & relate to client’s condition)
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What complications may occur, or what could go wrong?
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What interventions may prevent complications?
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Teaching
Describe the teaching that needs to be completed regarding any of the above issues while the
client is still in the hospital.
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Describe the teaching that needs to be completed regarding any of the above issues related to
the client’s discharge.
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Metropolitan Community College
Laboratory Values/Diagnostic Test Results
Laboratory/Diagnostic
Test
Ex: hemoglobin
Date of Test
7-27-09
Client Values
n/a
6
Normal Values
Male:
Female: 12-14
Metropolitan Community College
Relationship/Correlation
to Client
What is causing this result
for this client?
anemia due to GI
bleed
Medication Information Sheet
List first the medications you will administer, then PRN medications, then other medications client will receive.
Drug Name /
Classification
Therapeutic/pharm
Dose, Route,
Frequency, Time
of admin
Ex: Ibuprophen
NSAID/analgesic
800mg 3 times/day
oral 0700-1300-2000
Mechanism of
Action
Use for This
Client
(how it works in the
body)
Inhibits prostaglandin
synthesis
analgesic
Metropolitan Community College
Side Effects /
Interactions/toxic
effects
Nursing
Considerations/
CHF;MI;erythemia; GI
hemorrhage;agranulocytosis
Do not use in CV
surgery; take with
milk/food; no
alcohol;monitor dose
do not exceed
1200mg/24h
administration
concerns
Medication Information Sheet (cont’d)
Drug Name /
Classification
Therapeutic/pharm
Dose, Route,
Frequency
Mechanism of
Action
Use for This Client
(how it works in the
body)
Metropolitan Community College
Side Effects /
Interactions/toxic
effects
Nursing
Considerations/
administration concerns
Nursing Diagnosis
□ At which level of Maslow’s Hierarchy of Needs does this client fall on this shift?
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□ What is this client’s priority nursing diagnosis for this shift? ( Problem R/T _________AEB_________)
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□ What is the goal for this client with regards to his/her condition?
(SMART Goal)
Client will:
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□ List 5 nursing interventions and rationales for this client in order to meet this goal.
Interventions
Rationale
□ Did the client meet his/her goal? (If not, explain, and describe how the interventions/goal could be revised.)
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Metropolitan Community College