Beruflich Dokumente
Kultur Dokumente
NURSING PROGRAM
PRELIMINARY DATA SHEET FOR CLINICAL ASSIGNMENTS
Student: ______Mary Prefontaine___________________________Date: ______________October 20, 2012_________
Room # _-___ Patient (initials) ____-___Age _88____ Marital Status _W_ Residence: Home ___Other (specify) _Nursing
home____
Reason for Admission: _Confusion and increased behavioral issues_____________
_September 27, 2012_________
Date of Admission:
Medical Diagnoses: (definitions of each to be attached to this sheet) UTI, dehydration, delirium, and acute renal
failure_________________
Surgery: (definition to be attached to this sheet) Cystoscopy with right ureteral stent placement (November
4, 2011)
__Left cystoscopy (stone extraction with stent insertion)___________ Date
of Surgery: _ April 27, 2005_____
Concurrent Medical Problems: Diabetes Mellitus Type II, Hypertension, Kidney Stones, Gout, Encephalopathy
_____________________________________________________________________________________________
Allergies: ___No Known Allergies______________________________________________________ Code Status: DNR/DNI
______
NURSING CARE:
Diet (purpose) __Diabetic 2200 calories, Sodium 2000 mg_(renal
failure)___________________________________________________
IV (purpose, solution, rate)
______IV/INT___________________________________________________________________________________________
I & O:
YES
no
to unit ambulation
VS (how often) Every Shift Activity Order: Encourage out of bed daily. Restrict
Additional Nursing Actions (wound care, foley care, O2 therapy, safety precautions, etc.) _MRSA precautions,
01-03 (RAC)
06/01
01-03 (RAC)
06/01
_______________________________________________________________________________________________________________________
FOCUSED ASSESSMENT
Safety-At risk for falls (mobility)
Urinary System
Adult Failure to thrive
_______________________________________________________________________________________________________________________
PLANNED NURSING ACTIONS
Assist with mobility. Monitor urine for color, odor, frequency, amount, kidney stones. Monitor lab results.
_______________________________________________________________________________________________________________________
ANTICIPATED LEARNING NEEDS/PATIENT EDUCATION
Regarding medications; adverse effects, what to report and safety precautions. Proper nutrition, fluid
intake, and exercise.
01-03 (RAC)
06/01
PATIENT: ______________________________
Prefontaine__________________________
MEDICATION
Heparin,
Sodium INJ
DOSE
5,000
units
1 mL
TIME
Three
times
per day
ROUTE
Subcutaneo
us
NURSING
MEASURES
Prevention
&
treatment
of blood
clots
Assess vital
signs
Allergies
Review
BEERS
Monitor stool
and urine for
blood
Bleeding,
BLEEDING DISORDERS,
headache,
RECENT TRAUMA, SPINAL
dizziness,
PUNCTURE, GI ULCERS,
weakness, nausea, RECENT SURGERY,
gastrointestinal
INTRAUTERINE DEVICE,
distress, skin rash TUBERCULOSIS, PRESENCE OF
INDWELLING CATHETER,
PREGNANCY, AGE RELATED
Rash, hives,
itching, swelling
face, throat,
tongue, eyes, lips,
hands, feet,
ankles, lower legs;
hoarseness,
difficulty
breathing,
swallowing
Headache,
dizziness,
weakness, fatigue,
drowsiness &
depression
Acetamino
phen
325
mg
TAB
Twice
per day
Orally
Headaches
muscle
aches,
fever
reducer,
pain relief
Assess vital
signs
Assess for
side effects
Review
BEERS
Tamsulonsi
n
0.4
mg
Cap
Before
bed
Orally
Relaxes
muscles in
prostrate &
bladder so
that urine
flows easily
Assess vital
signs
Allergies
Review
BEERS
25 mg Before
bed
TAB
Orally
Treats
depression,
insomnia,
schizophre
nia,
anxiety
Assess vital
signs
Allergies
Review
BEERS
Assist with
Ambulation
Trazodone
01-03 (RAC)
STUDENT: Mary
SPECIAL CONSIDERATIONS
CORONARY
ARTERY DISEASE
CATARACT SURGERY
SYNCOPE (FAINTING)
RENAL
FAILURE, PREGNANCY,
VASODILATING OR
ANTIHYPERTENSIVE DRUGS
06/01
Allopurinol
Asprin
enteric
coated
Sertraline
Polyethyle
ne Glycol
3350
Powder
I-Vite
Protect
POLYVINYL
ALCOHOL
01-03 (RAC)
100
mg
TAB
Four
times
per day
Orally
Treats
gout,
seizures
Assess vital
signs
Allergies
Review
BEERS
Upset stomach,
drowsiness,
diarrhea, painful
urination, blood in
urine, unexpected
weight loss
MAINTAIN
325
mg
TAB
Daily
Orally
Prevent
blood clots
Assess vital
signs
Allergies
Review
BEERS
Nausea,
heartburn, blood
loss, bleeding
abnormalities,
ringing in ears,
mental confusion
CONCURRENT
50 mg Every
Mornin
TAB
g
Orally
Depression
, OCD,
panic
attacks,
PMS
dysphoric
disorder
Assess vital
signs
Allergies
Review
BEERS
Assess skin
Assess
kidney
function(test
s)
1
Packe
t
Daily
as
needed
Orally
Constipatio
n
2
TABS
Two
times
per day
Orally
Supplemen
t
multivitami
ns &
minerals
Assess VS
Monitor stool
for blood
Review
BEERS
Tooth staining,
increased
urination, stomach
bleeding, uneven
heart rate,
confusion, muscle
weakness
1
DROP
EVERY
DRY EYE
ASSESS
TEMPORARY
EXTERNAL
FOUR
BOTH
EYES
FLUID INTAKE TO
YIELD MORE URINE OUTPUT AT
LEAST 2 L PER DAY
USE OF
ANTICOAGULANTS,
RHEUMATOID ARTHRITIS,
ALLERGY TO SALICYLATES AND
OTHER NSAIDS
Drowsiness,
DIABETES MELLITUS
dizziness,
PREGNANCY/BREAST FEEDING
excessive
ST. JOHNS WORT
tiredness, pain,
burning, tingling
of hands or feet,
nervousness,
uncontrollable
shaking of a part
of the body,
blurred vision,
seizures, abnormal
bleeding
Assess for
Nausea, bloating,
PREGNANCY, BOWEL
possible
cramps, gas,
OBSTRUCTION, ULCERATIVE
contraindicati diarrhea, hives,
COLITIS, GASTRIC RETENTION,
ons or
abdominal
cautions
distension
Gather
baseline data
EFFECTS
SIDE
PAIN
EYE
USE ONLY
PREGNANT/BREAST FEEDING
06/01
SOLN
OPH
BLURRED
HOURS
AS
NEEDED
Glipizide
2.5
mg
TAB
Fosinopril
NA
Orally
Stimulates
insulin
making
Assess VS
Assess for
anorexia
Assess skin
Hypoglycemia, GI
distress, vomiting,
anorexia, skin
reactions,
increased risk of
cardiovascular
mortality, blisters
LOWER
10 mg Every
mornin
TAB
g
Orally
Hypertensi
on
Diabetic
nephropath
y
Reflex
tachycardia, chest
pain, heart failure,
ulcers, renal
failure, photo
sensitivity
ELDERLY HYPERSENSITIVITY,
HISTORY OF ANGIOEDEMA,
BILATERAL RENAL ARTERY
Insulin
Regular
INJ
Slidin
g
Scale
Three
times
per day
SubCutaneo
us
Review
BEERS
Baseline VS,
assess VS,
Assess for
adventitious
breath
Assess VS
Assess skin
Redness, swelling,
pain at injection
site, weight gain
AGE,
Insulin
Glargine
INJ
10
units
Before
bed
SubCutaneo
us
Assess VS
Assess food
intake
Assess skin
Redness, swelling,
pain at injection
site, weight gain,
constipation, skin
rash, hives, SOB,
trouble breathing,
low blood
pressure, swelling,
abnormal heart
beat, difficulty
swallowing
DIARRHEA, MALABSORPTION,
FEVER, INFECTION, RENAL OR
HEPATIC IMPAIRMENT,
HYPOTHYROIDISM SURGERY,
01-03 (RAC)
Every
day
VISION
Diabetes
Diabetes
STENOSIS
HYPOTHYROIDISM,
HYPERTHYROIDISM SURGERY,
PREGNANCY
PREGNANCY
06/01
PATIENT: ______________________________
DIAGNOSTIC TEST
01-03 (RAC)
DATE
DIAGNOSTIC TESTS/CONSULTS
NORMAL
PATIENT RESULTS
NURSING SIGNIFICANCE
06/01
01-03 (RAC)
06/01