PATIENT/CLIENT DATA – CLINICAL DECISION-MAKING WORKSHEET

Posted: May 5th, 2020

PATIENT/CLIENT DATA – 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 – CLINICAL DECISION-MAKING WORKSHEET

Week: 2

Patient Initials

CV

Sex

M

Age

47

Room

837

Admitting Date

5/19/2023

Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

Intractable headache

Attending physician/Treatment team:

Ayman M. Jabr, MD

Consults:

No consult

Present Diagnosis: (Why patient is currently in the hospital)

Headache and dizziness

ER Management: (if applicable)

Nile Township high school

Allergies:

Shrimp, Ibuprofen, Aspirin

Code Status:

Full code

Isolation: (type and reason)

none

Admission Height:

165.1 centimeters (5,5)

Admission Weight:

107.9 kilograms (237 lbs)

Arm Band Location (colors & reasons)

on the right arm and it’s white

Communication needs: (verbal, nonverbal, barriers, languages)

the patient has no communication barriers

Past Medical History: (pertinent & how managed)

Diabetes Mellitus

Gerd

Hypertension

Obstructive Sleep Apnea

Sciatica

Spinal Stenosis

Degenerative Joint Disease

Significant Events during this hospitalization but not during this clinical time: (include date, event and outcome)

Tests/Treatments/Interventions impacting clinical day’s care (include current orders)

Assessments and interventions: (Include all pertinent data)

Vital signs: (2 sets per day)

Time

8: 00

T

98.6

P

96

R

18

B/P

138/80

Time

13: 00

T

97.9

P

98

R

20

B/P

111/73

GI:

Diet: Regular

Swallow precautions:

Tube feedings:

NG / G tube:

Blood Glucose: (time & date)

Last bowel movement: (time & date)

Pertinent Labs/Test:

Assessments/Interventions: (stool, bowel sounds, tenderness, distention, appetite, nausea, vomiting)

Respiratory:

02 modalities:

02 Saturation: 96

Suction:

Resp Rx’s:

Trach: none

Chest Tubes: none

Pertinent Labs/Test:

Assessments/Interventions: (Lung sounds, cough, sputum, SOB)

Neurosensory:

Neuro checks:

Alert & Orientated: x4

Follows commands: yes

Speech Comprehensible: yes

Pertinent Labs/Test:

Assessments/Interventions:

(LOC, pupils, Glascow Coma scale, dizziness, headaches, tremors, tingling, weakness, paralysis, numbness)

patient had dizziness and headache

Cardiovascular:

Telemetry:

Pacemaker/IAD:

DVT Prevention: heparin (5000 units)

Daily Weights:

Pertinent Labs/Test:

Assessments/Interventions:

(peripheral pulses, heart sounds, murmurs, bruits, edema, chest pain, discomfort, palpitations)

Musculoskeletal:

Activity: independent

Traction: none

Casts/Slings:

Pertinent Labs/Test:

Assessments/Interventions:

(strength, ROM, pain, weakness, fractures, amputation, gait, transfers, CMS or 5 Ps

Renal:

Catheter (indwelling/external):

CBI:

Dialysis:

A/V access:

Pertinent Labs/Test:

Assessments/Interventions: (location, bruit, thrill)(urine-quality, burning with urination, hematuria, incontinent, continent, I & O)

Skin:

Braden Score:

Pertinent Labs/Test:

Assessments/Interventions:(bruising, characteristics, turgor, surgical incision, finger & toe nails, wounds, drains, bed type)

Pain:

Pain score: 10 in the head

Assessments/Interventions: acetaminophen was given

(scale used, location, duration, intensity, character, exacerbation, relief, interventions)

morphine

Vascular Access: (IV site)

Assessments/Interventions: (include type of fluid & access, location, dressing, date inserted, tubing change, Site Appearance)

Gyn:

Gravida/Para: none

LMP: none

Last Pap: none

Breast exam: none

Pertinent Labs/Test

Assessment/Interventions: (bleeding, discharge) none

Post-operative /procedural:

Assessments/Interventions: none

(immediate post procedure care)

Safety:

Call light:

Bed Rails:

Bed alarms: no need

Fall risk: not at 4 risk

Assistive Devices: none

Sitter use: none

Restraints (type, duration & reason):

Assessment/Interventions (modifications to room, environment, Patient)

Advance Directives/Ethical considerations:

DPOA: has no advanced directives

Hospice:

Pertinent Data (Labs, X-rays, Etc.)

Results

Normal Lab Values

Significance to your patient

WBC

7.2

5.2-12.4

RBC

5.37

4.7-6.2

HGB

17.3

12.0-15.0

HCT

48.9

37-50%

MCV

91.0

95.3

MCH

32.3

27-31

MCHC

35.5

32-36

Platelets

207

151-401

RDW

14.5

12-15%

MPV

8.3

7-9

CBC

PT

INR

APTT

Glucose

225

70-99

BUN

14

7-25

Creatinine

0.86

0.6-1.3

Sodium

134

135-145

Potassium

5.3

3.5-5.2

Cloride

97

98-107

Calcium

9.0

8.6-10.3

T Protein

6.4

Albumin

3.8

SGOT

SGPT

Alk Phos

69

Magnesium

Amylase

Lipase

CPK

LDH

Cholestrol

CK

CK-MB

Troponin I

Myoglobin

LDI

Urinalysis

Color

Character

Spec. Grav.

pH

Protein

Glucose

Acetone

Bilirubin

Blood

Nitr

Urobili

RBC

WBC

______________________________________
The 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:

Psycho/Social

The patient is married with two children.
He is employed as a teacher.
He is a member of the local church.
He is a social person and enjoys spending time with his family and friends.
He is coping well with his illness and is hopeful for a full recovery.
Cultural/Spiritual

The patient is of Hispanic descent.
He is Catholic.
His faith is important to him and he finds comfort in his religious beliefs.
His family and friends are also very supportive and he is grateful for their love and care.
Growth & Development

The patient is a 47-year-old man.
He is in the middle adult years.
He is at a stage in his life where he is balancing his work and family responsibilities.
He is also facing the challenges of aging, such as managing his health conditions.
Current Overall plan of care

The patient is being treated for a headache and dizziness.
He is taking medication for his headache and is being monitored for his dizziness.
He is also being evaluated for other possible causes of his symptoms.
Discharge plans and needs

The patient will be discharged from the hospital in a few days.
He will need to continue taking his medication and follow up with his doctor.
He will also need to make lifestyle changes, such as getting regular exercise and eating a healthy diet.
Teaching needs

The patient will need to be taught about his medication and how to take it properly.
He will also need to be taught about his diet and exercise plan.
He will also need to be taught about the signs and symptoms of his condition and when to seek medical attention.
Medications

The patient is taking acetaminophen for his headache.
He is also taking a medication for his dizziness.
He will continue to take these medications after he is discharged from the hospital.
Normal lab values and its significance to the patient

The patient’s lab values are within normal limits.
This means that his body is functioning normally and that his illness is being treated effectively.