Student Name: Faculty Name: Professor Galia Date: 11/11/2022
Weekly Nursing Process Worksheet
Instructions: Each clinical day each student will
... [Show More] develop a nursing process outline for one patient of their choice. This portion of your clinical day is of the utmost importance. It provides you with key teaching-learning opportunities for your clinical practice and focuses on your ability to demonstrate patient care management with specific disease states through the AAPIE: Assess Analyze Plan Implement Evaluate. In this manner, what is the major purpose for using Tanner's model of clinical Judgment? involves recognizing that an issue exists (patient problem), analyzing information about issues (clinical data about a patient), evaluating information (reviewing assumptions & evidence), and making conclusions.
These are quick notes and what should be assessed and what should be done throughout the shift. Expect to hone the skills of communication by focusing on the essentials of the care that was provided in handoff report and be able to “give report” utilizing the AAPIE format. These will be discussed in clinical and in post conferences with the faculty. Upload to CANVAS After the conference.
DIRECTIONS
What needs to be done today. Completed Not Completed Comments
Assess the patient. X X X
Know the admitting diagnosis and hold status X X X
Read the most recent physician and nursing notes. X X X
Have the chart in hand or electronic chart open and be ready to report
• allergies
• medication times scheduled
• fluids,
• stat lab test results and pre-op or procedures (if pertinent) X X X
IDENTIFICATION DATA:
Patient Initials: Patient Age: _58 Gender F M Allergies M Isolation: Covid Precautions
Other:
SITUATION
I am reporting about: Patient initial: L Room # 329
The problem and situation I am reporting about is:
Problem: patient with type 1 diabetes post op and developing diabetic ketoacidosis
Situation: patient
If this is a serious problem, identify what the code status is. Code/DNR Full Code
IDENTIFYING DATA
Why is the patient in the hospital: (Provide brief statement which led to the patient’s admission to hospital/facility i.e., need rehab post CVA)?
Admitting DX: Right knee replacement surgery Surgery:
BACKGROUND
• Briefly state why the patient is in the hospital and give a synopsis of the treatment to date.
A 58 year old man with controlled type 1 diabetes is in the hospital following a knee replacement surgery on his right leg. Two days post-operation, the patient has developed diabetic ketoacidosis and is presenting with a fruity breath and altered mental state.
Dr Debra Wallace 12/14/2021 Med/Surg
• What is the admission plan?
Take vital signs and monitor and administer antibiotics prior to surgery. Following right knee replacement, monitor. After diagnosis of diabetic ketoacidosis: give fluids for 24-36 hours, begin electrolyte therapy, and use insulin therapy to decrease the patient's blood glucose level (Mendez, 2017).
• Give the vital signs, pain level, oximetry, and how much oxygen is being given. (If none state none)
HR 100 bpm, RR 32/ minute, BP 116/ 78 mmH, Temperature 97 fahrenheit, O2: 96% , given O2: none
• Relate the complaint given by the patient e.g., pain and anxiety level.
The patient has reported a pain level of 4/10 on a 1-10 scale and has an anxiety level of 8/10 on the 1-10 scale.
• Relate the physical assessment pertinent to the problem, especially any changes.
The patient’s neurological assessment of decreased alert and orientation, and is an indicative sign of diabetic ketoacidosis.
• Pay special attention to mental status, skin temperature and emotional state of the patient
PERTINENT HISTORY: (include pertinent history)
DM Type 1/GI/GERD/GU/ HTN/ CVA/ CKD/CAD/PVDCOPD/Smoker/ETOH/Drug Abuse/Dementia
Psych: Altered Living Situation: Living at home with wife and kids
ASSESSMENT:
Give your conclusions about the present situation. Words like "might be" or "could be."
are helpful. A diagnosis is not necessary. (i.e., Patient’s tongue swelling might be from side effects from ACE drugs)
The patient has altered mental status and a fruity breath with a high glucose level of 468 mg/dL. The patient could be experiencing diabetic ketoacidosis
If the situation is unclear at least try to indicate what body system might be involved. The system involved is endocrine and cardiac
State how severe the problem seems to be. (Patient is having a severe chest pain from ischemia to cardiac vessels) The patient is having altered mental status, and is having a severely high blood glucose level
If appropriate, state the problem could be life threatening such as medication adverse effects.
(Pt is experiencing Red Man Syndrome from a severe reaction to Vancomycin infused too rapidly) Patient is experiencing diabetic ketoacidosis from a severe reaction to the recent surgery
ANALYSIS OF ASSESSMENT: use the template on the next page [Show Less]