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Clinical update template 2

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Clinical update template 2

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Clinical update template 2

  1. 1. Name: Dave Jay S. Manriquez Submission Date: October 22, 2016 Dates of Shifts: October 17 and 20, 2016 Clinical Update # 2 Number and Complexity of clients/residents 35 patients admitted in total from October 17-20, 2016. All of them are PATH patients, having different diagnosis mostly musculoskeletal, neurovascular, and respiratory complications. This time is more on knowing the unit routine from a day shift and night shift standpoint. Within this week I was assigned to five patients to give medication, assessed, and performed nursing skills such as wound dressing and staple removal. Clients AssessmentFocus: 1. Pain– fromthe openwound 2. SkinAssessment–both buttocksand boththighshave reddenedanddryareas 3. Vital Signs 4. Wound Assessment– presence of infectedleft buttocklesionandrightand left thighslesion 5. Anemia- due to chemoand radiationtherapy 6. Abdominal Assessment – constipationpossibleeffectof painmeds PriorityProblemtoTract: 1. Pain 2. Sign of infection 3. Constipation 4. Bleeding Possible Exams: 1. Bloodwork - RBC, Hgb,Hct, WBC Client 1 D.G.  Primary Diagnosis: Infectedbuttockslesion  Secondary Diagnoses: MetastaticLung CA – needchemotherapy  Medications: Connect with diagnoses Name Route Diagnosis Glaxal base cream Topical Reddenedanddry areas inbothbuttocks and thigh Flagyl Cream Topical Infectedbuttocks lesion Hydromorphone PO For Pain Polyethylene glycol PO Occasional Constipation Sennosides PO Constipation Ferrousgluconate PO Iron supplement  Nursing Skills/Interventions: Wound Dressing(Leftbuttockchange daily,Rightandleftinnerthighevery3days),Monitoring  Nursing responsibilities & duties other than direct client nursing care: GivingMedications,Wounddressing,Monitoring,Assistindailyactivities, Documentation,Communicatingpatientneeds,Collaborationwithpreceptor regardinghercare
  2. 2. AssessmentFocus: 1. Pain– fromhip fracture 2. Peripheral Vascular Assessment - Neurovascular,CWMS 3. Vital Signs 4. Abdominal Assessment –pt. istakingpainmedication 5. MobilityAssessment PriorityProblemtoTract: 1. Pain 2. Decrease Mobility 3. Constipation 4. As of Oct 20, 2016, pt bump herleftfooton the side of the walker,there isaformationof hematomainthe lateral side of the ankle – momentarilyadvice to use wheelchairinsteadthe walker. Possible Exams:  My Strengths: I communicate effectivelytopatient.Administer medicationcorrectlyatthe exactdue time. Coachable indoingnursingskills. Complete documentationandreplenishingnew formsinpatientchart.  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, preceptor, and instructor.  Extended Care: Why is the resident in EC? PATH: For continuous monitoring,patienthasstill anopenwound onthe leftbuttock,rightandleft thighsandrashesthat needto be takencare off,she still goingforherlast chemotherapy,andmostof all she still needtofindashelter. Goal of Care: To monitoropenwound status,dressingperprotocol; assessingpaindailyby offeringscheduledandPRN analgesics; toeducate patienttofollow medicationregimen. Discharge Planning: PatientD.G.is (familysocial),meaningshe still needtofinda shelterwhendischarge withthe helpof asocial workerand BC housing.She has3 oldersiblings,nochildren,andlivingalone before hospitalization.OTmayinvolve tohelpher withhismovementandpain,and to restore herskillsneededfordailyliving.Patientisinlow income bracket, definitelyshe needhelpfromasocial worker. A home care nurse will be visitingheronce discharge. Client 2 J.B.  Primary Diagnosis: Left hipfracture – hip precautionjustlifted  Secondary Diagnoses: Brain tumor(craniotomyx2),hypothyroidism, seizures,depression,Addisondisease  Medications: Connect with diagnoses Name Route Diagnosis Acetaminophen PO Lefthipand leftleg pain Levothyroxine PO Hypothyroidism Carbamazepine PO Seizure Sertraline PO Depression Fludrocortisone PO Addisondisease Lorazepam PO Antianxiety, sedation  Nursing Skills/Interventions: NeurovascularassessmentCWMS, Hip precautionsuchas encouragingtouse abductorpillow,avoidcrossingleg, avoidbendingforwardorkneesmustbe lowerthanhipswhile setting,and
  3. 3. 1. Oct 21, 2016 schedule togo to RCH for an ankle x-raytorule out fracture,schedule forD- dimertest,injectedwith dalteparinmomentarily.She reportednopainon the ankle site. AssessmentFocus: 1. Vital Signs – BP, PR,and RR, O2 sat 2. GCS – Neurovascular Assessment,LOC 3. RespiratoryAssessment 3. MobilityAssessment –she is usinga 2 wheel walkerbutshe preparedtouse a wheelchair. PriorityProblemtoTract: 1. Shortnessof Breath,O2 sat 2. Decrease Mobility 3. Hallucination,behaviorand attitude goingdownthe bedto use bad legfirstbefore goodleg,anddothe reverse whengoingbackto bed,and usinga walkertoaid mobility.  Nursing responsibilities & duties other than direct client nursing care: GivingMedications, Monitoring,Assistindailyactivities, Documentation,Communicatingpatientneeds,Collaborationwith preceptor regardinghercare.  My Strengths: I communicate effectivelytopatient.Administer medicationcorrectlyatthe exactdue time,observing7rightsand2 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, preceptor, and instructor.  Extended Care: Why is the resident in EC? PATH: For continuous monitoring, andregainingphysical strength. Goal of Care: Promote muscularstrengthinthe lowerextremitywithhelp fromPT and OT, to educate patient tofollow medicationregimen. Toincrease exercise tolerance:will situpinchair3x/dayin highchairto maintainhip precaution.Toattenddailyexerciseinagroup x5/7. To practice use of 2 wheel walkertoall meals.Tryto be independentaspossibleindoingADL’s. Discharge Planning: PatientJ.B.is(familysocial),meaningshe needto finda shelterwhendischarge.Momentarilywhendischarge she will be leavinginaprivate apartmenttogetherwith hersisterandmomwhichhasa stair.OT may involve tohelpherwithhismovementandpain,andto restore herskillsneededfordailyliving. Patientisinlow income bracket, don’thave a job, definitelyshe needhelpfromasocial worker. Client 3 C.D.  Primary Diagnosis: Exacerbationof COPD– Now clear  Secondary Diagnoses: Stroke, BrainAneurysm,hallucinationpsych (orientedx3inthe morning;confuse sometimesatnight);claustrophobic  Medications: Connect with diagnoses Name Route Diagnosis Loxapine PO Hallucination Nitroglycerine Patch Topical To preventanginaor heartattack Salbutamol Inhaler Inhalation For COPDto increase airwayopening
  4. 4. Possible Exams: 1. ABG 2. Head CT Scan or MRI AssessmentFocus: 1. Vital Signs – BP, PR,and RR, O2 sat 2. GCS – Neurovascular Assessment,LOC Atorvastatin PO Control cholesterol productiontoprevent stroke. Rivaroxaban PO Anticoagulant Diltiazem PO Antihypertensionto preventstroke and aneurysm  Nursing Skills/Interventions: Glasgow Coma Scale - Neurovital assessment,QPA –level of orientation (reorientation),Respiratory Assessment,Vital Signs –O2 sat,BP, PR,and RR.  Nursing responsibilities & duties other than direct client nursing care: GivingMedications, Monitoringbehavior,assistindaily activities,Documentation,Communicatingpatientneeds,Collaborationwith preceptorregardinghercare.CheckingO2 sat andgivingappropriate amount of oxygen.  My Strengths: I communicate effectivelytopatient.Administer medicationcorrectlyatthe exactdue time,observing7rightsand2 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, preceptor, and instructor.  Extended Care: Why is the resident in EC? PATH: For continuous monitoringonherbreathingandmental state.  Goal of Care: To monitorpatientbehavioral aspecttowardsociety,to people aroundher, toeducate patienttofollow medicationregimen,to preventstroke andaneurysm. Discharge Planning: PatientC.D.is(familysocial), meaningshe needto finda shelterwhendischarge. She hastwochildren,mightbe whendischarge she will temporarilylivewithone of herchildren.OTmayinvolve tohelpher to restore herskillsneededfordailyliving.Patientisinlow income bracket, definitelyshe needhelpfromasocial worker. Whenable tofinda newshelter for her,she needa home oxygen,home care nurse mightvisitherorcare aide to do showerandADL’s,and daughtermaydo hergrocery. Client 4 S.D.  Primary Diagnosis: Seizures,social admit(socialadmission)  Secondary Diagnoses: Developmentaldelay,COPD,HTN,Afib,Gout, CVA,Hypothyroidism, childhoodmeningitis
  5. 5. 3. RespiratoryAssessment 3. MobilityAssessment –she is usinga 2 wheel walker. PriorityProblemtoTract: 1. Shortnessof Breath,O2 sat 2. Decrease Mobility 3. Seizure andmental state/behavior Possible Exams: 1. ABG 2. Head CT Scan or MRI 3. ChestX-ray  Medications: Connect with diagnoses Name Route Diagnosis Aspirin PO Use as anticoagulantto preventheartattack, strokes,andchestpain Allopurinol PO Gout Clonazepam PO Antiseizure Diltiazem PO For hypertension Levothyroxine PO Hypothyroidism Risperidone PO Antipsychotic–social admit  Nursing Skills/Interventions: Glasgow Coma Scale - Neurovital assessment,QPA –level of orientation (reorientation),Respiratory Assessment(encouragetouse CPAPwhengoingtosleepatnight),Vital Signs – O2 sat, BP,PR.  Nursing responsibilities & duties other than direct client nursing care: GivingMedications, Monitoringbehavior,assistindaily activities,Documentation,Communicatingpatientneeds,Collaborationwith preceptorregardinghercare.CheckingVital signsesp.BPandO2 sat.  My Strengths: I communicate effectivelytopatient.Administer medicationcorrectlyatthe exactdue time,observing7rightsand2 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, preceptor, and instructor.  Extended Care: Why is the resident in EC? PATH: For continuous monitoringonherbreathingandmental state.  Goal of Care: To monitorpatientbehavioral aspecttowardsociety,to people aroundher, toeducate patienttofollow medicationregimen,to preventstroke andseizure. Encourage ptto exercise,performADL’s,towalk to dininghall formeals. Discharge Planning: PatientS.D.is(familysocial), meaninghe needto finda shelterwhendischarge. He hastwobrothersand a mom,mightbe whendischarge he will temporarilylivewithone of hissiblings.OTmay involve tohelphimtorestore his skillsneededfordailyliving.Patientisinlow income bracket,definitelyhe needhelpfromasocial worker.Whenable to
  6. 6. AssessmentFocus: 1. Vital Signs – BP, PR 2. GCS – Neurovascular Assessment,LOC Priority ProblemtoTract: 1. Pain 3. Hallucination,behaviorand attitude Possible Exams: 1. Head CT Scan or MRI 2. ChestX-ray finda new shelterforhim,he still needtobe monitoredbyhisfamily,do groceryfor him. Client 5 P.J.  Primary Diagnosis: Fall bilateral wristandfacial,afib,COPD  Secondary Diagnoses: Celiacdisease,herniarepair,aneurysm, smoker, cataracts, hypothyroidism, confuse  Medications: Connect with diagnoses Name Route Diagnosis Apixaban PO Patienthasafib Atorvastatin PO To lowercholesterol formation,prevent aneurysm Citalopram PO Antidepressant Levothyroxine PO Hypothyroidism Quetiapine PO Patientisconfuse, hallucination Melatonin PO Sedation,patient havinghard time to sleep,onandoff the bed  Nursing Skills/Interventions: Glasgow Coma Scale - Neurovital assessment,QPA –level of orientation(reorientation),VitalSigns,behavior monitoring  Nursing responsibilities & duties other than direct client nursing care: GivingMedications, Monitoringbehavior,assistindaily activities,Documentation,Communicatingpatientneeds,Collaborationwith preceptorregardinghercare.Wanderguardon,reorientingpatientwhenvery confuse.  My Strengths: I communicate effectivelytopatient.Administer medication correctlyatthe exactdue time,observing7rightsand2 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, preceptor, and instructor.
  7. 7.  Extended Care: Why is the resident in EC? PATH: For continuous monitoringandwatchingmental state.  Goal of Care: To monitorpatientbehavioral aspecttowardsociety,to people aroundher, toeducate patienttofollow medicationregimen,to preventstroke andaneurysm. To assistinexercisesof bilateral upper extremities,andrange of motion.Toassiston washing.Makingsure foodis glutenfree.Checkcognitioneveryshift,orientate ptq3-4 hrs. For mobility,pt uptochair for all mealsandgo to bathroomfor toileting.Forfall risk,hip protectorand bedalarmon. Discharge Planning: PatientP.J.is(home health), meaningshe hasa home and a familytolive with. OTmayinvolve tohelphertorestore herskills neededfordailyliving.Patientisinlow income bracket,definitelyshe need helpfroma social worker. Mental state of the patientneedtobe monitored by the family.Guardthe patientif neededbecause there isapossibilitythat she will be wanderingaround.Fall riskprecautionatall time shouldbe implemented.

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