Clinical Worksheet

Kenneth Bronson
Jasmyn Gould
1. Initial: K,B
2. Age: 27
3. Gender/Race: WM
4. Code status: full code
5. DX: Pneumonia
6. Length of stay: 1 day
7. Allergies: NKA at ADM, newly discovered allergies to Ceftriaxone
8. HCP: Dr. Davis
9. Consults: Respiratory
10. Isolation: Standard
11. Fall Risk: yes
12. Transfer: none
13. IV type: peripheral
14. IV location: right hand/ right forearm
15. Fluid/rate: NS 75 ml/ hr
16. Critical labs: Hct 48, WBC 14.3, Platelets 457
17. Other services: none
18. Consults needed: none
19. Pt. has hx of COPD and Dx of PNeumoina
20. COPD, current smoke (2 packs/day for 10 yrs)
21. Shift Goals/ Pt. educational needs:
 Admin. Meds. As prescribed as order
 Monitor VS q.15mins for 1st hr following anaphylaxis
 Educate pt. on unknown allergy, ceftriaxone
 Maintain SpO2>92%
22. Path to discharge:
 pt. understands meds and new allergy.
 Pt is aware of current tx. For anaphylactic reaction.
 Pt. VS remain stable
23. Path to death or injury: Pneumonia coupled with drug allergic reactions has worsened
pts. ability to breathe. Pt. continues to have decrease SpO2 and increase heart rate
24. Alerts
 SOB
 O2 stat <92%
 Altered level of consciousness
25. What assessments will focus on for this pt.
 Monitor respiratory sx
 Monitor cardiovascular sx
 Monitor I&Os
26. Complications
 Pleural effusion
 Depression
 Respiratory failure
27. Nursing interventions:
 Constant pulse ox. Monitoring
 Ecg monitors
 Antibiotic meds
 Pt. education
28. Managements of care: What need to be done for this pt. today?
 Pt. education
 Assessing pt knowledge of med. Allergies
 Antibiotic therapy
 Relief of pt. anxiety of depression
 SpO2 monitoring
 Comfort care

29. Priorities for managing the pt. care today

 Respiratory assessments
 Medication admin as ordered
 Assess ABC’s
 Pt. education
30. What aspects of the pt. care can be delegated and who can do it?
 Assistant personnel can take. VS, pt. comfort care, pt. positioning, and turning
 Nurses can acquire signatures for consent to treat forms, assess VS, apply
respiratory measures, admin. Med as order, H2T assessments, ensure treatment is
working for pt. and pt. educations
 Doctor prescribes med. Me with pt.