Nursing 101

Clinical Preparation Sheet

Student Name: SunSearr Ruffin Client Initials: Mae S Room #:225B Gender: F Code Level: Full Code Primary Diagnosis: (brief definition)
Cerebrovascular accident (CVA refers to any functional abnormality of the Central Nervous System that occurs when the normal blood supply to the brain is disrupted, as by a blood clot or a ruptured blood vessel, and vital brain tissue dies. Cerebrovascular accident is commonly called Strokes. Causes:

Date: 11/28/11 Activity: limited Age: 78 Diet: low sugar, low salt

Secondary Diagnosis: (brief description) Diabetes Mellitis (? Type II) - Diabetes mellitus is a
group of metabolic diseases characterized by high blood sugar (glucose) levels, that result from defects in insulin secretion, or action, or both. Diabetes mellitus, commonly referred to as diabetes (as it will be in this article) was first identified as a disease associated with "sweet urine," and excessive muscle loss in the ancient world. Elevated levels of blood glucose (hyperglycemia) lead to spillage of glucose into the urine, hence the term sweet urine. In patients with diabetes, the absence or insufficient production of insulin causes hyperglycemia. Diabetes is a chronic medical condition, meaning that although it can be controlled, it lasts a lifetime.

Cerebral Thrombosis blockage in the thrombus (clot) that has built up on the wall of the brain artery. Cerebral Embolism blockage by an embolus (usually a clot) swept into the artery in the brain. Hemorrhage Rupture of a blood vessel and bleeding within or over the surface of the brain
Textbook signs and symptoms of Primary Diagnosis: Headache, Dizziness and confusion, Visual disturbance, Slurred speech or loss of speech, Difficulty of swallowing, permanent facial droop, hemiparesis, Hemiplegia

Textbook signs and symptoms of Secondary Diagnosis: Polyuria, polydipsia, weight-loss, blurred vision, inc food consumption, generalized weakness. Also symptoms of D. ketoacidosis: nausea vomiting dizziness, coma, death. May cause CVD, PVD and sclerosis of the kidneys.

List all skills planned for the performance of nursing care. This list of skills indicates that the student has reviewed and practiced these skills prior to clinical. Textbook page numbers must be written next to skills. Write in times skills are to be performed when appropriate.

Allergies NKA
7-8: pre-conference. 8-9: meet & shift report, introduce and begin assessment of client (orientation, vitals and fine motor while eating), assess swallowing while eating, assist as necessary, ensure heel protectors are in place, monitor intake including supplement, give meds, ROM assessment and exercises of head and extremities, Pulse Ox reading, assess lung and bowel sounds, (mechanical lift x2) check state of mattress when client is moved to bath chair. 9-10: full shower, (mechanical lift x2): assist as necessary; moisturize (Zinc Oxide 2% to peri and buttocks area); continue physical assessment, gross motor assessment during washing and dressing. OOB to w/c with gel cushion, foot buddy, rt padded arm rest, lt lap board, lt lateral support, bi-lat ele legs, 11-12: accu-check and insulin as necessary. check skin integrity and change brief as necessary or requested, monitor output, prepare for lunch, 12-1: post-conference Throughout shift maintain proper body mechanics, adhere to standard precautions, and regularly assess patient and patients environment for alterations to safety, as well as neuro-vascular assessment.

Client: Mae S. Allergies NKA

Medications Time Drug 0900 Aspirin (chewable) 0900 Lopressor

RM: 225B

Diagnosis: CVA w/ Rt side hemiparesis; Diabetes Mellitis,

Generic Name aspirin metoprolol Prednisone

Dosage 81mg 50mg ? 10mg 5mg

Route PO PO PO PO PO

Frequency Daily UD as directed Tid Daily Daily

Classification Platelet aggregation inhibitor prevention of recurrent MI Beta-blocker dec force and rate of heat contractions HTN, angina pectoris* Anti-inflammitory, immunosuppressant Monitor BP Antidepressant - SSRI

BP
0900 Lexapro 0900 Norvasc escitalopram amlodipine

PRN Medications Zinc Oxide to peri- and buttock area Novolg Insulin for coverage (0700 & 1100 accu-check)

Student Name: SunSearr Ruffin Clients Initials Margaret D. and Primary Medical-Surgical Diagnosis: DM, PVD Physical Safety (P.S.) Oxygenation (O2) Activity, Rest and Elimination (E) Nutrition (N) Psychosocial WellSleep (ARS) Being (PSB)

Skin: Texture: warm, moist Turgor: elastic

Lesions: none wounds : none Drainage: none

edema: none
rashes: none petechiae: none ecchymosis: none

ulcers: none ~3.5 cm reddened area at rt hip Mucous membranes: pink, moist Body Temperature: Hair: clean, hair piece in place Head & neck: symmetrical, no deformities Eyes: PEARRLA Ears: clean, clear Breasts: anteriorly present Abdomen: soft, w/ bowel sounds Restraining devices: none Nameband: in place Allergies: narcotics, Braden Scale: Morse FA: Pain: denies
PT (10.8-12.9) : PTT (21.2-33.9) : not in Platelets (130-400) : chart INR (2-4) :

Vital Signs Baseline Current Skin color/ texture: face: symmetrical fingers: clean, warm to touch Chest assessments size/ shape:
symmetrical

Posture: straight Gait: steady with walker

Curvatures: kyphosis

Bowel Characteristics: loose patterns of defecation: every other day Last BM: 11/22/11 artificial orifices and collecting devices: none Bladder Characteristics: yellow patterns of urination: infrequent artificial orifices and collecting devices: none Vomitus : none Gastric suctioning: none Urinalysis Urine RBC (0-5): not charted BUN (8-26) : 25 Creatinine(.4-1.0): 1.0 Medications:
Docusate sodium: promote electrolyte and H2O secretion into colon

Height: Weight: Body build: obese Appetite usual/ current: Type of diet: Low sweets Condition of hair: clean, femal pattern baldness Fingernails: clean, clear Toenails: Fluid I/O: I O electrolytes K (3.5-5.1): 4.6 Cl (98-107): 112 CO2 (21-32): 26 Na (136-145): 143 Ca (8.5-10.1): 9.8 Protein (6.4-8.2): 6.3 BS (70-99): 124

Extremities : all present and mobile except rt lower. BKA range of motion (ROM) active: head 100% arms, 50% leg 50% passive: 75%
Contractures: none

Level of consciousness: Alert, Oriented to person, place. Easily re-oriented to time. Receptiveness to communicate: highly Non-verbal communication: smiles, gestures, hand-holding Cultural diversity: The holidays are good but people shouldnt skip over Thanksgiving. Health beliefs: People would feel better if they just slowed down Placement in the life cycle: Mature: Ego-integrity vs ego despair: (+) ego-integrity Social history: enjoys spending time with family and roommate

patterns of respirations: normal lung sounds:

O2 usage: none Cough: none

Secretions: none Presence of blanching/ Clubbing: none 7 Ps Pallor: none Pain: none Paralysis: none Parasthesia: none Polar: none Puffiness: none Pulselessness: none
Hgh(12-16): not charted Hct(37-47): not charted WBC(4.8-10.8): not charted

Activities of Daily Living (ADL) Toileting : no assist Bathing : partial assist Dressing :partial assist Feeding : no assist Mobility assistive devices: wheelchair or standard walker Sleep patterns: normal Pain: denies Medications:

BP(100-140/60-100):
160/80

Medications: Zinc Oxide 2% topical - combat skin

HR: 52 RR (12-32):20 SpO2 (95-100): 93 CXR: none Medications:

Occupation: Family: 3 daughters, 1 BMI: son, 8 grandchildren Level of anxiety: none Medications: Mood: pleasant Calcium carbonate Recent stressors: + vitamin D: Tx positive: going home and prevention of for Thanksgiving calcium deficiency Novolin Insulin: Concerns about antidiabetic agent current illness Tapazole: inc Advanced directives: appetite no Code Level : Full Code Organ donor status: not charted

STUDENT PLAN FOR NURSING CARE

Student Name: Client Problem: Clients Initial: SunSearr K. Ruffin Risk for alterations in elimination MD Developed: Spring 1993 Revised: Spring, 2009
Reviewed: Yearly

NURSING DIAGNOSIS: Risk for dysfunctional gastrointestinal motility R/T decreased mobility secondary to BKA of right leg
GOALS
Client will ambulate

IMPLEMENTATION

RATIONALE (Include Source and Page Numbers) 1. Ascertain whether client is experiencing anxiety, stress or other psychogenic factors. (p 542, Doenges) 2. Emphasize benefits of regular exercise and promoting normal GI function. (p 539, Doenges) 3. Recommend maintenance of normal weight to decrease risk associated with GI disorders. (p543, Doenges) 4. Discuss fluid intake appropriate to individual situation. Water is necessary to general health and GI function. (p539, Doenges) 5. Palpate abdomen to note masses etc., auscultate abdomen note hypo or hyperactive bowel sounds. ( p537, Doenges)

length of one wing 2x during shift at 1000 and 1030 to increase

gastrointestinal motility during shift on 11/23/11

1. Assess client for current stressors or anxiety during patient interview at beginning of shift. 2. Encourage ambulation length of one wing 2x during shift;10 am, 10:30 3. Encourage 100% of meal intake; at breakfast, at lunch. 4. Encourage adequate fluid intake; 150 mL during 8 to noon shift. 5. Assess for pain and bowel sounds x4 quadrants pre and post ambulation exercises.

EVALUATION:

STUDENT PLAN FOR NURSING CARE

Student Name: Client Problem: Clients Initial: SunSearr K. Ruffin Developed: Spring 1993 Revised: Spring, 2009
Reviewed: Yearly

NURSING DIAGNOSIS: Risk for deficient fluid volume R/T medications [diuretics] secondary to HTN
GOALS IMPLEMENTATION RATIONALE (Include Source and Page Numbers) 1. Encourage oral intake; offer fluids between meals and regularly throughout the day. (p381, Doenges) 2. Discuss individual risk factors and potential problems. (p 382, Doenges) 3. Provide fluids in manageable cup or drinking straw. (p 381, Doenges) 4. Monitor vital signs for changes. (p3811, Doenges) 5. Assess causative or contributing factors of lower intake. (p380, Doenges)

Client will drink at least 150 mL of fluids during my shift from 08:00 to 12:00 on 11/23/11

1. Offer 40 mL of fluid every hour on the hour. 2. Explain need for adequate hydration with current medications. 3. Offer fluids in small 40mL cup with straw. 4. Assess BP and HR at onset and close of shift. 5. Ask client what drinks she most enjoys and try accommodated based on diet and availability.

EVALUATION:

Luzerne County Community College

NUR 101 EVALUATION of the Student Plan for Nursing Care

Student Name: Yes No

Assessments:
a. thorough (use format from lecture) b. pertinent

Client Initial:
COMMENTS

c. subjective & objective data (correct terminology) d. grouped acc. To LCCC health problem

Nursing Diagnosis:
a. NANDA approved b. Etiology is correctly stated

c. Supported by assessments (numbers placed beneath Nsg. Diagnosis) d. Supporting data highlighted in health problem cluster

Planning (Goals)
a. correct format including time/date b. appropriate to diagnosis c. measurable d. realistic

Yes No
Implementations:
a. stated correctly b. specific

COMMENTS

c. individualized

d. congruent with other therapies

e. thorough (including times each is performed)

Rationale:
a. based on accepted nursing principles

Evaluation:
a. identifies goal achievement

b. includes subjective and objective data related to goal achievement

c. if goal is partially met or unmet identify area of process needing modification

Developed: 9/95 Reviewed: Yearly Revised: May, 2005