Date: ________ Student Name: _______________________ Clinical Site:____________________________________Clinical Site Instructor:___________________________________ __________________________________________Room #_405_________Client Initials: ____SR___ ____Client age: ____52 years_______  Gender: ___Male_______Allergies: Diphenhydramine______________________________ Code Status: ___Full code______________ ________________Diet/Nutrition: _________Regular___________________ Activity: _______________________________ Fall Risk: Yes / No Yes (High fall risk)Use of (type/amount/frequency): Alcohol: ___________________ Tobacco (pack years): ________________________Treatments: _______________________________ IV/Tubes/Ostomies: ______________________________________Dressings/Wounds: (type & location) _Shoulder-healing, Back-Tegaderm and clear absorbent.__________________________________________________________________Oxygen: (delivery method & amount) ____N/A___________________________ Dialysis: ______N/A_____________________LAB RESULTS: (minimum of 2 labs) Why is this lab significant for this client’s condition? Write down ABNORMAL lab results and include what the NURSE needs to monitor for or do related to the abnormal lab result under the significance column. ONLY USE ABNORMAL LAB RESULTS QSEN: Informatics, Safety SLO: 3, 8DateTestNormal ValueClient ValueSignificance7/24 Sodium____135-145_   1327/25 Hemoglobin 14-18    9.4 __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________LABSLook at the 2 labs you looked up for this week. For each of the labs look up what body system or system(s) it tells you about, what does an elevated level mean, and what does a low level mean. Also, are there any special considerations or client education regarding prepping the client for the test? (example: fasting for 6 hours, etc.) QSEN: Informatics, Safety SLO: 3, 8Lab Test#1: __Sodium 135-145_______________Systems affects: ______________________________________________Elevated level: _____________________________________________________________________________Low level: _132___________________________________________________________________________Lab Test #2: _Hemoglobin 14-18_________________Systems affects: ______________________________________________Elevated level: _____________________________________________________________________________Low level: 9.4_______________________________________________________________________________Date: ____________ Client Initials: _SR_____ Student Name: ___________________________­­­­____________________Medical Diagnosis(s): (found in paper chart)Admitting/Primary: Motor Vehicle Accident____________________________________   ______________________________________Medical History (includes medical and surgical)Acute post hemorrhagic anemia _____________________________________Alcohol abuse ___________________________________  _____________PTSD____________________________________Adjustment disorder with other symptoms___________________________________ ____Traumatic ischemia of muscle__________________________________ ________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ ______________________________________End of Shift Report or SBAR: QSEN: Informatics, Team-Work Collaboration SLO: 3DATETIMEDate: ____________ Client Initials: ______ Student Name: _______________________________________­­­­_________PRN Medication List (found in paper chart) QSEN: Safety, Evidence Based Practice. SLO: 2, 4Medication(Include dose, time, route, & Frequency)ClassificationIndication for useOxyCODONE   (Immediate release) 5mg tablet-10mg POIbuprofen 400mg tablet PO q6hMedication Data SheetDate: ____________ Client Initials: ______ Student Name: ___________________________­­­­________________________(Scheduled medications to be given to your client during your clinical shift) QSEN: Safety, Evidence Based Practice. SLO: 2, 4Drug Name, Dose, Route   & scheduleDrug Classification,   Expected action & indication for useSide Effects/ Adverse   Reactions(List 3-5)Medication/Food   Interactions(List 3-5)Nursing Administration   Considerations & Assessments(List 3-5)Client education &   Evaluation of Medication Effectiveness(List 3-5)Mirtazapine 7.5mg PO at HSNicotine 21mg/24hr Patch   TransdermalGabapentin 100mg capsule POMethocarbamol 500mg   tablet-1000mg POEnoxaparin 40mg/0.4ml   injection 40mg subcutaneousMelatonin 3mg tablet PO at   HSDate: ____________ Client Initials: ______ Student Name: _______________________________________­­­­_________Patient________________________ Room:__________ Hallway:_____________Nurse: ____________________________ NA: _________________________TempOral/TympanicHRRegular/ IrregularBPLaying/Sitting/Standing Right/leftResp.O2 %Room Air/ Oxygen _____LPainLocation: Description:Pain Intervention:Edema:Location:__________________ Degree:________________ pitting/non-pittingLung sounds:Right_______________________  Left_________________________Cough?_____________________ SOB?__________________________Bowel Sounds_________________________________________Date of Last BM______________Trach:Times Suctioned:Type of Trach suction: In-Line / SterileVent Settings:RRTVHALAPEEPModeLMVSensitivityInsp TimeFiO2O2LKeep O2 above%Treatments Done?Foot care Done?PATHOPHYSIOLOGY: For each diagnosis below,provide a 3-5 sentenceexplanation of the pathophysiology of the problem.(**we count sentences**)QSEN: Evidence Based Practice, Informatics, Client Centered Care. SLO: 1, 2, 41.Primary Diagnosis: Open displaced fracture of pelvis(3-5 sentences)Treatments: (3 minimum)Potential complications: (3 minimum)Potential Nursing Diagnosis (2 minimum)Potential Nursing Interventions: (2 minimum)2.Diagnosis: Alcohol dependence with withdrawal(3-5 sentences)Treatments: (3 minimum)Potential complications: (3 minimum)Potential Nursing Diagnosis (2 minimum)Potential Nursing Interventions: (2 minimum)3.Diagnosis: Closed fracture of multiple ribs of left side(3-5 sentences)Treatments: (3 minimum)Potential complications: (3 minimum)Potential Nursing Diagnosis (2 minimum)Potential Nursing Interventions: (2 minimum)4.Diagnosis: Closed fracture of transverse process of lumber vertebra(3-5 sentences)Treatments: (3 minimum)Potential complications: (3 minimum)Potential Nursing Diagnosis (2 minimum)Potential Nursing Interventions: (2 minimum)5.Diagnosis: Acute blood loss anemia(3-5 sentences)Treatments: (3 minimum)Potential complications: (3 minimum)Potential Nursing Diagnosis (2 minimum)Potential Nursing Interventions: (2 minimum)6.Diagnosis: Respiratory failure(3-5 sentences)Treatments: (3 minimum)Potential complications: (3 minimum)Potential Nursing Diagnosis (2 minimum)Potential Nursing Interventions: (2 minimum)7.Diagnosis: Acute pain due to trauma(3-5 sentences)Treatments: (3 minimum)Potential complications: (3 minimum)Potential Nursing Diagnosis (2 minimum)Potential Nursing Interventions: (2 minimum)8.Diagnosis: Transection of urethra(3-5 sentences)Treatments: (3 minimum)Potential complications: (3 minimum)Potential Nursing Diagnosis (2 minimum)Potential Nursing Interventions: (2 minimum)Student evaluation of clinical performance:Please describe any procedures/skills you performed/ observed during the clinical experience. Also, include your assessment of how well the day went.

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