PATIENT\/CLIENT DATA \u2013 CLINICAL DECISION-MAKING WORKSHEET<\/p>\n
I need help completing the Psycho\/Social, Cultural\/Spiritual needs, Growth & Development, Current Overall plan of care, Discharge plans and needs, Teaching needs, completing the medications sections, and putting in the normal lab values and its significance to the patient.<\/p>\n
PATIENT\/CLIENT DATA \u2013 CLINICAL DECISION-MAKING WORKSHEET<\/p>\n
Week: 2<\/p>\n
Patient Initials<\/p>\n
CV<\/p>\n
Sex<\/p>\n
M<\/p>\n
Age<\/p>\n
47<\/p>\n
Room<\/p>\n
837<\/p>\n
Admitting Date<\/p>\n
5\/19\/2023<\/p>\n
Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?<\/p>\n
Intractable headache<\/p>\n
Attending physician\/Treatment team:<\/p>\n
Ayman M. Jabr, MD<\/p>\n
Consults:<\/p>\n
No consult<\/p>\n
Present Diagnosis: (Why patient is currently in the hospital)<\/p>\n
Headache and dizziness<\/p>\n
ER Management: (if applicable)<\/p>\n
Nile Township high school<\/p>\n
Allergies:<\/p>\n
Shrimp, Ibuprofen, Aspirin<\/p>\n
Code Status:<\/p>\n
Full code<\/p>\n
Isolation: (type and reason)<\/p>\n
none<\/p>\n
Admission Height:<\/p>\n
165.1 centimeters (5,5)<\/p>\n
Admission Weight:<\/p>\n
107.9 kilograms (237 lbs)<\/p>\n
Arm Band Location (colors & reasons)<\/p>\n
on the right arm and it’s white<\/p>\n
Communication needs: (verbal, nonverbal, barriers, languages)<\/p>\n
the patient has no communication barriers<\/p>\n
Past Medical History: (pertinent & how managed)<\/p>\n
Diabetes Mellitus<\/p>\n
Gerd<\/p>\n
Hypertension<\/p>\n
Obstructive Sleep Apnea<\/p>\n
Sciatica<\/p>\n
Spinal Stenosis<\/p>\n
Degenerative Joint Disease<\/p>\n
Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)<\/p>\n
Tests\/Treatments\/Interventions impacting clinical day\u2019s care (include current orders)<\/p>\n
Assessments and interventions: (Include all pertinent data)<\/p>\n
Vital signs: (2 sets per day)<\/p>\n
Time<\/p>\n
8: 00<\/p>\n
T<\/p>\n
98.6<\/p>\n
P<\/p>\n
96<\/p>\n
R<\/p>\n
18<\/p>\n
B\/P<\/p>\n
138\/80<\/p>\n
Time<\/p>\n
13: 00<\/p>\n
T<\/p>\n
97.9<\/p>\n
P<\/p>\n
98<\/p>\n
R<\/p>\n
20<\/p>\n
B\/P<\/p>\n
111\/73<\/p>\n
GI:<\/p>\n
Diet: Regular<\/p>\n
Swallow precautions:<\/p>\n
Tube feedings:<\/p>\n
NG \/ G tube:<\/p>\n
Blood Glucose: (time & date)<\/p>\n
Last bowel movement: (time & date)<\/p>\n
Pertinent Labs\/Test:<\/p>\n
Assessments\/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)<\/p>\n
Respiratory:<\/p>\n
02 modalities:<\/p>\n
02 Saturation: 96<\/p>\n
Suction:<\/p>\n
Resp Rx\u2019s:<\/p>\n
Trach: none<\/p>\n
Chest Tubes: none<\/p>\n
Pertinent Labs\/Test:<\/p>\n
Assessments\/Interventions: (Lung sounds, cough, sputum, SOB)<\/p>\n
Neurosensory:<\/p>\n
Neuro checks:<\/p>\n
Alert & Orientated: x4<\/p>\n
Follows commands: yes<\/p>\n
Speech Comprehensible: yes<\/p>\n
Pertinent Labs\/Test:<\/p>\n
Assessments\/Interventions:<\/p>\n
(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)<\/p>\n
patient had dizziness and headache<\/p>\n
Cardiovascular:<\/p>\n
Telemetry:<\/p>\n
Pacemaker\/IAD:<\/p>\n
DVT Prevention: heparin (5000 units)<\/p>\n
Daily Weights:<\/p>\n
Pertinent Labs\/Test:<\/p>\n
Assessments\/Interventions:<\/p>\n
(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)<\/p>\n
Musculoskeletal:<\/p>\n
Activity: independent<\/p>\n
Traction: none<\/p>\n
Casts\/Slings:<\/p>\n
Pertinent Labs\/Test:<\/p>\n
Assessments\/Interventions:<\/p>\n
(strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps<\/p>\n
Renal:<\/p>\n
Catheter (indwelling\/external):<\/p>\n
CBI:<\/p>\n
Dialysis:<\/p>\n
A\/V access:<\/p>\n
Pertinent Labs\/Test:<\/p>\n
Assessments\/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O)<\/p>\n
Skin:<\/p>\n
Braden Score:<\/p>\n
Pertinent Labs\/Test:<\/p>\n
Assessments\/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)<\/p>\n
Pain:<\/p>\n
Pain score: 10 in the head<\/p>\n
Assessments\/Interventions: acetaminophen was given<\/p>\n
(scale used, location, duration, intensity, character, exacerbation, relief, interventions)<\/p>\n
morphine<\/p>\n
Vascular Access: (IV site)<\/p>\n
Assessments\/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)<\/p>\n
Gyn:<\/p>\n
Gravida\/Para: none<\/p>\n
LMP: none<\/p>\n
Last Pap: none<\/p>\n
Breast exam: none<\/p>\n
Pertinent Labs\/Test<\/p>\n
Assessment\/Interventions: (bleeding, discharge) none<\/p>\n
Post-operative \/procedural:<\/p>\n
Assessments\/Interventions: none<\/p>\n
(immediate post procedure care)<\/p>\n
Safety:<\/p>\n
Call light:<\/p>\n
Bed Rails:<\/p>\n
Bed alarms: no need<\/p>\n
Fall risk: not at 4 risk<\/p>\n
Assistive Devices: none<\/p>\n
Sitter use: none<\/p>\n
Restraints (type, duration & reason):<\/p>\n
Assessment\/Interventions (modifications to room, environment, Patient)<\/p>\n
Advance Directives\/Ethical considerations:<\/p>\n
DPOA: has no advanced directives<\/p>\n
Hospice:<\/p>\n
Pertinent Data (Labs, X-rays, Etc.)<\/p>\n
Results<\/p>\n
Normal Lab Values<\/p>\n
Significance to your patient<\/p>\n
WBC<\/p>\n
7.2<\/p>\n
5.2-12.4<\/p>\n
RBC<\/p>\n
5.37<\/p>\n
4.7-6.2<\/p>\n
HGB<\/p>\n
17.3<\/p>\n
12.0-15.0<\/p>\n
HCT<\/p>\n
48.9<\/p>\n
37-50%<\/p>\n
MCV<\/p>\n
91.0<\/p>\n
95.3<\/p>\n
MCH<\/p>\n
32.3<\/p>\n
27-31<\/p>\n
MCHC<\/p>\n
35.5<\/p>\n
32-36<\/p>\n
Platelets<\/p>\n
207<\/p>\n
151-401<\/p>\n
RDW<\/p>\n
14.5<\/p>\n
12-15%<\/p>\n
MPV<\/p>\n
8.3<\/p>\n
7-9<\/p>\n
CBC<\/p>\n
PT<\/p>\n
INR<\/p>\n
APTT<\/p>\n
Glucose<\/p>\n
225<\/p>\n
70-99<\/p>\n
BUN<\/p>\n
14<\/p>\n
7-25<\/p>\n
Creatinine<\/p>\n
0.86<\/p>\n
0.6-1.3<\/p>\n
Sodium<\/p>\n
134<\/p>\n
135-145<\/p>\n
Potassium<\/p>\n
5.3<\/p>\n
3.5-5.2<\/p>\n
Cloride<\/p>\n
97<\/p>\n
98-107<\/p>\n
Calcium<\/p>\n
9.0<\/p>\n
8.6-10.3<\/p>\n
T Protein<\/p>\n
6.4<\/p>\n
Albumin<\/p>\n
3.8<\/p>\n
SGOT<\/p>\n
SGPT<\/p>\n
Alk Phos<\/p>\n
69<\/p>\n
Magnesium<\/p>\n
Amylase<\/p>\n
Lipase<\/p>\n
CPK<\/p>\n
LDH<\/p>\n
Cholestrol<\/p>\n
CK<\/p>\n
CK-MB<\/p>\n
Troponin I<\/p>\n
Myoglobin<\/p>\n
LDI<\/p>\n
Urinalysis<\/p>\n
Color<\/p>\n
Character<\/p>\n
Spec. Grav.<\/p>\n
pH<\/p>\n
Protein<\/p>\n
Glucose<\/p>\n
Acetone<\/p>\n
Bilirubin<\/p>\n
Blood<\/p>\n
Nitr<\/p>\n
Urobili<\/p>\n
RBC<\/p>\n
WBC<\/p>\n
______________________________________
\nThe Psycho\/Social, Cultural\/Spiritual needs, Growth & Development, Current Overall plan of care, Discharge plans and needs, Teaching needs, medications, and normal lab values and its significance to the patient:<\/p>\n
Psycho\/Social<\/p>\n
The patient is married with two children.
\nHe is employed as a teacher.
\nHe is a member of the local church.
\nHe is a social person and enjoys spending time with his family and friends.
\nHe is coping well with his illness and is hopeful for a full recovery.
\nCultural\/Spiritual<\/p>\n
The patient is of Hispanic descent.
\nHe is Catholic.
\nHis faith is important to him and he finds comfort in his religious beliefs.
\nHis family and friends are also very supportive and he is grateful for their love and care.
\nGrowth & Development<\/p>\n
The patient is a 47-year-old man.
\nHe is in the middle adult years.
\nHe is at a stage in his life where he is balancing his work and family responsibilities.
\nHe is also facing the challenges of aging, such as managing his health conditions.
\nCurrent Overall plan of care<\/p>\n
The patient is being treated for a headache and dizziness.
\nHe is taking medication for his headache and is being monitored for his dizziness.
\nHe is also being evaluated for other possible causes of his symptoms.
\nDischarge plans and needs<\/p>\n
The patient will be discharged from the hospital in a few days.
\nHe will need to continue taking his medication and follow up with his doctor.
\nHe will also need to make lifestyle changes, such as getting regular exercise and eating a healthy diet.
\nTeaching needs<\/p>\n
The patient will need to be taught about his medication and how to take it properly.
\nHe will also need to be taught about his diet and exercise plan.
\nHe will also need to be taught about the signs and symptoms of his condition and when to seek medical attention.
\nMedications<\/p>\n
The patient is taking acetaminophen for his headache.
\nHe is also taking a medication for his dizziness.
\nHe will continue to take these medications after he is discharged from the hospital.
\nNormal lab values and its significance to the patient<\/p>\n
The patient’s lab values are within normal limits.
\nThis means that his body is functioning normally and that his illness is being treated effectively.<\/p>\n","protected":false},"excerpt":{"rendered":"
PATIENT\/CLIENT DATA \u2013 CLINICAL DECISION-MAKING WORKSHEET I need help completing the Psycho\/Social, Cultural\/Spiritual needs, Growth & Development, Current Overall plan of care, Discharge plans and needs, Teaching needs, completing the medications sections, and putting in the normal lab values and its significance to the patient. PATIENT\/CLIENT DATA \u2013 CLINICAL DECISION-MAKING WORKSHEET Week: 2 Patient Initials […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1,36,15,22,18,23,45,44,26,24,29,43,37],"tags":[140,232,229,230,224,236,259,233,235,226,265,234,225,227,223,231],"class_list":["post-872","post","type-post","status-publish","format-standard","hentry","category-ace-homework-tutors","category-ace-my-assignment","category-ace-my-homework","category-ace-tutors","category-cheapest-homework-help-online","category-help-with-homework-assignments","category-homework-for-you","category-homework-ace-tutors-assignment-help","category-homework-answers","category-homework-solving-website","category-homework-tutors","category-online-homework-help","category-essay-ace","tag-ace-tutors","tag-apa-citation-format-assignment","tag-assignment-help-by-uks-no-1-writing-service","tag-assignment-writers-australia-college-student","tag-assignment-writers-canada-university-cost","tag-buy-essay-usa","tag-free-ai-english-assignment-writers-china","tag-help-write-a-page-assignment","tag-i-need-someone-to-do-my-assignment-within-hours","tag-in-page-paper-write-an-essay","tag-need-assistance-completing-the-assignment","tag-need-to-write-an-essay","tag-professional-assignment-writers-usa","tag-uae-1-cheap-assignment-writing-service","tag-write-a-word-essay","tag-write-pages"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/posts\/872","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/comments?post=872"}],"version-history":[{"count":0,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/posts\/872\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/media?parent=872"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/categories?post=872"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/essays\/wp-json\/wp\/v2\/tags?post=872"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}