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.
