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RNSG 1262 Nursing Case Study

Student Name: _________________________________________ Dates of Care: _______________________Client Initials: ________ Gender: _____ Age: ____ RM# _____ Med Team/MD: ___________________Admitting Diagnosis: _______________________________________________ Date of Admission: __________________Concurrent Diagnoses: ___________________________________ Surgery: ________________________ Date: ______________Allergies to Drugs or Foods: _____________________ Advanced Directives / Code Status: ______________

Therapeutic Modalities/ MD Orders:

Data Collection Day Clinical Day 1 Clinical Day 2

Vital Signs/SpO2: Frequency

I & O/ Fluid Restrictions

Diet

Scheduled Diagnostics

Activity Level

Dressing Change Orders

Resp. Therapy

Physical Therapy

Daily Weights

SCD, TEDS, CPM

Accuchecks

Daily Labs:

Other Treatments:

Summaries of Progress Notes:

Doctor’s Data Collection Day

Doctor’s Data Collection Day #1

and or Day #2

Nurse’sData collection Day

Nurse’sData Collection Day #1

and/or Day #2

Pathophysiology of Admitting Diagnosis:

Pathophysiology of Concurrent Diagnoses:

Description of Surgical Procedures:

Lab Data Sheet - highlight abnormals

Labs/X-rays/Dx Tests Results

Normal Range

Date Result

DateResult

DateResult

Correlation to Pathophysiology: Interpret results as well as correlating with the client’s medical condition:

Complete Blood Count: WBC 3.6-11.0

RBC 4.5-5.90Hg 13.5-17.5Hct 41-53Platelets 150-450

ESR N/A

Differential

Other:

MCV 30-98MCH 26-34MCHC 31-37RDW 12.0-14.6Mean Platelet 6.8-10.2

Chemistry: Na 135-145

K 3.5-5.1

Cl 94-106

Glucose 60-100

Total Protein 6.2-8.1

Albumin 3.5-5.0

CO2 20-29

BUN 7-25

Cr 0.7-1.60

Calcium 8.2-10.3

Other:Bilirubin Total 0.2-1.2

Bilirubin Direct 0.0-0.4

ALT 0-35

AST 0-38

Mg 1.6-2.2

Phos 2.4-4.6

Alk Phos 32-108

Lactic Acid (Plasma)

0.5-2.2

Anion Gap 5-19

Coagulation Studies: INR 0.8-1.2

PT 22-37

PTT

Urinalysis:

Clarity ------Color -----Bilirubin Negative

Blood Negative

Glucose Negative

Ketones Negative

Leukocytes Negative

pH 5-8Protein NegativeSp Gravity 1.001-

1.035Urobilonogin 0-1mg/dL

Microscopic:WBC 0-5 HPFRBC 0-5 HPFEpithelial 0-5 HPFBacteria 0-450

HPFCasts 0-1

UDS

Amphetamine Negative

Barbituate Negative

Benzodiazapine Negative

Cannabinoids Negative

Opiates Negative

PCP Negative

Cocaine Negative

Arterial Blood Gases:pH 7.35-7.45PCO2 32-48PO2 83-108O2 sat -----

HCO3 21.0-28.0

Culture & Sensitivity:note source/growth and sensitivity

Exudate Culture -------Gram Stain --------

Fungal Calcaflour --------

Radiological Studies:

X-Ray - Chest

Sonogram Extremity

CAT Angiograph

EKG:

Diagnostic Tests: describe results

Vancomycin Level

------

Blood Antibody ScreenImmunology

Hep B- Antigen Non Reactive

Hep B- Antibody Non Reactive

Hep A Non Reactive

Hep C Non Reactive

Trade Name Pharmacological Class Dose/Route Rationale for this client Major Side Effects Nursing Implications for Safe Administration and

Evaluation of Therapeutic Effects

Generic Name Mechanism of Action Max Dose

Physical Assessment - Data Collection Day

Neurosensory

Level of Consciousness: Alert: Oriented: Confused: Lethargic: Unresponsive: to Verbal stimuli Y N Painful Stimuli: Y NGlasgow /coma Scale Rating (if needed) ______Disoriented: Person Place TimeBehavior: _________________________

Communication/Speech Pattern: ______________

Pupil size: Rt. ______ Lt. ______Reaction: __________Vision Impairment: Y N

Describe: ___________________________________ Glasses: Y N

Sensation: Intact LossesDescribe:___________________________________

Hearing loss: : Y N Describe:___________________________________

History or current alterations affecting this system:Sedative medications

Possible Nursing Dx:

Musculoskeletal

Motor Strength: 0 = complete paralysis, 1= flicker of movement, 2 = overcome gravity, 3 = 50% of normal4= 75 % of normal strength, 5= 100% of normal strengthRUE ____ LUE ____ RLL ____ LLE ____

Describe:__________________________

Mobility: _______________________________________________________________________

ROM - L= Limited

Activity/ Restrictions: ____________________________________________________________________

Risk for Fall: : Y N

Use of Assistive Devices: ____________________________________________________________________________________________________________________

History or current alterations affecting this system:


Respiratory

Respiratory Rate: ____Pattern: _____ Normal _____ Shallow _____ Rapid_____ Labored_____Cough: Non –Productive ___ Productive ___ Describe:______________________________________________________________________________

Chest inspection (expansion, deformities): _______________________________________________________________________________________________

Use of accessory muscles: yes ___ no: __ Lung Sounds: 1 = clear, 2 = diminished, 3 = crackles, 4 = rhonchi, 5 = wheezing, 6 = friction rub.

RUL ___ RML __ RLL _____ LUL ___ LLL_____

O2 saturation: Room Air:___ ______ On Oxygen Therapy:________



Cardiovascular:

Apical pulse: ____Rhythm: regular irregular Heart Sounds: Aortic _____Pulmonic ______ Tricuspid _____Mitral ______ Describe abnormalities: _________________________________________________________________

Capillary Refill: < 3sec > 3 sec.

Pulses: describe as 0 = absent, 1 = doppler, 2 = weak, 3 = normal and 4 = bounding

___RR __LR ____RDP ___LDP ___ RPT ___LPT

Dialysis Shunt: : Y N Condition: __________________________________________________

Homan’s sign: ____ Positive ____ Negative N/A

Edema: describe as 0=none, 1+= barely detectable, 2+ indentation, 3+ indentation, 4+ indentation = > 10mm

RUE ____ LUE ____ LLE ____ RLE _____ Periorbital_____ Sacral______

JVD: : Y N



Gastrointestinal

Abdomen: distended non-distended Bowel Sounds: describe as A = absent, N = normal, HA= hyperactive, HO= hypoactive___ RUQ ___RLQ ___LUQ ____LLQ

Last BM: __4/10/11___(date)diarrhea _____ constipation ____ normal__x___

Ostomy: Y NType/describe fistula: _________________________ __________________________________________

N/G decompression: : Y N Describe: ______________________________________________________________________________________Feeding tube/PEG: : Y NFeeding type/rate: ____________________________Patency/Residual:____________________________



Genitourinary

Patterns: continent ___ incontinent ___ nocturia___ ___ frequency ___ urgency ___ dysuria _____ urinary retention ___

Appearance: clear ___ cloudy ___yellow ___ pink ___ amber ____bloody____

Catheter: : Y NType-____________________________________

24 hour I&O______________________________



Integument

Temp: ___warm, ___hot, ___coolMoisture: ___dry, ___moist, ___diaphoreticColor: ___normal, ___ pale, ___ cyanotic, ___ flushed ___Other (describe)______________________________Skin Condition:_____normal_____________________________________________________________

Incision/wounds:(describe)___________________________________________________________________________________________________________

Dressing Orders:____________________________________________________________________________________________________________________

Braden Scale Score: _____PUSH Tool Score: __________



Nutrition

Adm. Weight: ________Current Weight:_______Ideal Body Weight:____History of Weight loss: ___________________________________________________________________

Diet History: ___ ___________________________________________________________________________________________________________

Appetite:____ _________________________

Percent of meal eaten: Breakfast:________Lunch:_________ Dinner: _________Snacks:_____________________________________

Describe condition of teeth/denture/oral mucosa: _________________________________________________________________________________________________________________________________Other: _____________________________________

Blood glucose monitoring: Reading/time ______________ Reading/time_____________



Pain Assessment (describe)

Type of Pain: Acute______ Chronic____

Location: ________________________

Intensity/Rating:_____________________________

Pattern: ____________________________________

Nature : _______________________________________________________________________________________________________________________________________________



List all scheduled, prn, and IV medications

Physical Assessment - Data Collection Day of Care# 1 Vital Signs:__________________________

Neurosensory



Musculoskeletal



Respiratory



Cardiovascular:



Gastrointestinal



Genitourinary



Integument



Nutrition



Pain Assessment:(describe)



Wound / Surgical Incision Assessment:Assessment Wound #1 Wound #2 Wound #3Type of woundand StageLocation

Length

Width

Depth

Drainage

Odor

Undermining / TunnelingWound bed tissue type

Factors affecting wound healing:

Miscellaneous Information:

Physical Assessment - Data Collection Day of Care# 2 Vital Signs:___________________________

Neurosensory



Musculoskeletal



Respiratory



Cardiovascular:



Gastrointestinal



Genitourinary



Integument



Nutrition



Pain Assessment:(describe)



Wound / Surgical Incision Assessment: Document changes for day two.Assessment Wound #1 Wound #2 Wound #3Type of woundand StageLocation

Length

Width

Depth

Drainage

Odor

Undermining / TunnelingWound bed tissue type

Factors affecting wound healing:

Miscellaneous Information:

Assessment Data: Psychosocial/ Cultural

Stressors: Behaviors/Coping Strategies

Identified culture/ethnicity Religion Occupation Family Role

Developmental Task:Clients Developmental Task According to Erikson: Describe if the client has/has not achieved their developmental task. Include positive/negative resolution and justify your conclusion.

Psychosocial Diagnosis:

Understanding of Illness/Treatments

Community Referral

Nursing Dx Priority_1__Hospital Outcome/Goal: Nursing Interventions:

Designate I: independent D: dependent C: collaborative/interdependent

Scientific Rationale Evaluation(Specify as goal met/unmet/or partially met)

Nursing Diagnosis/Analysis:

Correlation to Patho or Psycho-physiology

Discharge Goal: Teaching Plan:

Nursing Dx Priority___ Hospital Outcome/Goal: Nursing Interventions:Designate I: independent D: dependent C: collaborative/interdependent



.



Nursing Dx Priority____ Hospital Outcome/Goal: Nursing Interventions:Designate I: independent D: dependent C: collaborative/interdependent





Nursing Dx Priority____ Hospital Outcome/Goal: Nursing Interventions:Designate I: independent D: dependent C: collaborative/interdependent




Discharge Goal: Teaching Plan:.

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