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Clinical Update Template

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Clinical Update Template - Preceptorship

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Clinical Update Template

  1. 1. Name: Dave Jay S. Manriquez Submission Date: October 13, 2016 Dates of Shifts: October 10 and 11, 2016 Clinical Update # 1 Number and Complexity of clients/residents 33 patients admitted in total from October 10-11, 2016. All of them are PATH patients, having different diagnosis mostly musculoskeletal and neurovascular complications. First day is more on orientation with the unit and buddy up with preceptor to learn their routine. On my second day in the unit I was assigned to three patients to give medication and assessed. Clients AssessmentFocus: 1. Pain– fromcellulitisand amputatedtoe 2. Peripheral Vascular Assessment - Neurovascular,CWMS 3. Vital Signs 4. GenitourinaryAssessment 5. Respiratory/Chest Assessment 6. Wound Assessment 7. Anemia- due to cirrhosis 8. Abdominal Assessment – constipationpossibleeffectof painmeds 9. MobilityAssessment PriorityProblemtoTract: 1. Pain 2. Decrease Mobility 3. Shortnessof breath 4. Constipation 5. Hypoglycemia/Hyperglycemia 6. Bleeding Possible Exams: 1. Bloodwork - RBC, Hgb,Hct, WBC,lytes,+K 2. ChestX-Ray 3. Urinalysisandstool exam Client 1 J.F.  Primary Diagnosis: Cellulitisrightlegandrightfoot,toesamputation  Secondary Diagnoses: COPD,ETOH, Hep C+, DM2, LiverCirrhosis  Medications: Connect with diagnoses Name Route Diagnosis Budesonide + Formeterol Inhaled COPD InsulinLispro SC injection DM2 InsulinNPH30/70 SC injectionDM2 MD2 Cyanocobalamin PO LiverCirrhosis Metformin PO DM2 Methadone PO Cellulitis,amputation  Nursing Skills/Interventions: Wound Dressing,Monitoring  Nursing responsibilities & duties other than direct client nursing care: GivingMedications,Wounddressing,Monitoring,Assistindailyactivities, Documentation, Communicatingpatientneeds,Collaborationwithpreceptor regardinghiscare  My Strengths: I communicate effectively topatient. Administer medicationcorrectlyatthe exactdue time.Completedocumentationand replenishingnew formsinpatientchart.
  2. 2. AssessmentFocus: 1. Pain– fromfracture andulcer 2. Peripheral Vascular Assessment - Neurovascular,CWMS 3. Vital Signs 4. GenitourinaryAssessment 5. Wound Assessment 6. Anemia- due to cirrhosis 7. Abdominal Assessment –to checkobstruction 8. MobilityAssessment PriorityProblemtoTract: 1. Pain 2. Decrease Mobility 3. Constipation –less movement 4. Bleeding Possible Exams: 1. Bloodwork - RBC, Hgb,Hct, WBC,lytes,+K 2. Urinalysisandstool exam  Learning challenges or needs: QPA to be done more effectively and fast, locating supplies in the unit, communicating to the other member of the health team.  Extended Care: Why is the resident in EC? PATH: For continuous monitoring,patienthasstill an openwoundneedtobe takencare off before goinghome. Goal of Care: To treat openwound,topreventshortnessof breath,to educate patienttofollow medicationregimen. Discharge Planning: PatientJ.F.is(home health),meaninghe isgoing home.He has familytolive withandcare for him.PT and OT may involve to helphimwithhismovementandpain,andtorestore hisskillsneededfor dailyliving.Patientisinlow income bracket,definitelyhe needhelpfroma social worker. Client 2 J.A.  Primary Diagnosis: Role Out Bowel Obstruction  Secondary Diagnoses: Rule outbowel obstruction,Cirrhosis,Chronic legulcers,Lefthipfracture  Medications: Connect with diagnoses Name Route Diagnosis Heparin SC injection Left hip fracture Lactulose Solution PO Bowel Obstruction Polyethylene Glycol PO Bowel Obstruction Cyanocobalamine PO Cirrhosis Folic Acid PO Cirrhosis Melatonin PO Sleeping issue  Nursing Skills/Interventions: NeurovascularassessmentCWMS, WoundAssessment,Monitoring.  Nursing responsibilities & duties other than direct client nursing care: GivingMedications,Wounddressing,Monitoring,Assistin dailyactivities,Documentation,Communicatingpatientneeds,Collaboration withpreceptorregardinghercare  My Strengths: I communicate effectivelytopatient.Administer medicationcorrectlyatthe exactdue time,observing7rightsand2 identifiers.Complete documentationandreplenishingnew formsinpatient chart.
  3. 3. AssessmentFocus: 1. Vital Signs 2. GCS – Neurovascular Assessment 3. MobilityAssessment PriorityProblemtoTract: 1. Pain 2. Decrease Mobility 3. Bleeding Possible Exams: 1. Bloodwork - RBC, Hgb,Hct 2. Head CT Scan or MRI  Learning challenges or needs: QPA to be done more effectively and fast, locating supplies in the unit, communicating to the other member of the health team.  Extended Care: Why is the resident in EC? PATH: For continuous monitoring,patienthasstill anopenwoundneedtobe takencare off before goinghome. Goal of Care: To treat openwound, promote muscularstrengthinthe lowerextremity withhelpfromPTand OT, toeducate patient tofollow medicationregimen. Discharge Planning: PatientJ.A.is(home health),meaning she isgoing home.She hasfamilytolive withandcare forher. A home care nurse will be visitinghertohelpherwithwoundcare. Patientisinlow income bracket, definitelyshe needhelpfromasocial worker. Client 3 H.M.  Primary Diagnosis: Sub dural hemorrhage  Secondary Diagnoses: CAD,Dementia,Bipolar  Medications: Connect with diagnoses Name Route Diagnosis Dalteparin SC Injection CAD,sub dural hemorrhage Aspirin PO CAD LithiumCarbonate PO Bipolar Quetiapine PO Bipolar,Dementia Sertraline PO Antidepressantpt. presentcondition Trazodone PO Antidepressantpt. presentcondition  Nursing Skills/Interventions: Glasgow Coma Scale, Neurovital assessment, QPA – level of orientation.  Nursing responsibilities & duties other than direct client nursing care: GivingMedications, Monitoringbehavior,Assistindaily activities,Documentation,Communicatingpatientneeds,Collaborationwith preceptorregardinghercare  My Strengths: I communicate effectivelytopatient.Administer medicationcorrectlyatthe exactdue time,observing7rightsand2
  4. 4. identifiers.Complete documentationandreplenishingnew formsinpatient chart.  Learning challenges or needs: QPA to be done more effectively and fast, locating supplies in the unit, communicating to the other member of the health team.  Extended Care: Why is the resident in EC? PATH: For continuous monitoring, patientneedCTscanor MRI priorto discharge.  Goal of Care: To monitorpatientbehavioral aspecttowardsociety,to people aroundhim, toeducate patienttofollow medicationregimen,to preventstroke andaneurysm. Discharge Planning: PatientH.M. is(home health),meaninghe isgoing home.He has familytolive withandcare for him.OT may involve tohelphim to restore hisskillsneededfordailyliving.Patientisinlow income bracket, definitelyhe needhelpfromasocial worker.

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