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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 ____________________________________________________________ ______________________________________________________________________________ Textbook description of the client’s condition. (Include signs/symptoms and pathophysiology) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Signs/symptoms noted on arrival to the hospital. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 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) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ What complications may occur, or what could go wrong? ______________________________________________________________________________ ______________________________________________________________________________ What interventions may prevent complications? ______________________________________________________________________________ ______________________________________________________________________________ Teaching Describe the teaching that needs to be completed regarding any of the above issues while the client is still in the hospital. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Describe the teaching that needs to be completed regarding any of the above issues related to the client’s discharge. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 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? __________________________________________________________________________________________ □ What is this client’s priority nursing diagnosis for this shift? ( Problem R/T _________AEB_________) __________________________________________________________________________________________ __________________________________________________________________________________________ □ What is the goal for this client with regards to his/her condition? (SMART Goal) Client will: __________________________________________________________________________________________ _________________________________________________________________________________________ □ 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.) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Metropolitan Community College