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Patient history: The patient has history of traumatic brain injury secondary to motor vehicle accident and with cognitive and physical deficits spasticity / hemiplegia of left side of the body . A

Patient history: The patient  has history of traumatic brain injury secondary to motor vehicle accident and with cognitive and physical deficits spasticity  / hemiplegia of left side of the body .

Admission diagnosis: altered mental status.

Discharge diagnosis summary: AMS / possible acute toxic encephalopathy, and SIRs.

Ola was 40yrs he presented to the hospital with Altered mental status, he was lethargic and not following commands in hospital. She was admitted for AMS (altered mental status) .he was Keppra loaded as she appeared post-ictal . placed on seizure precaution with neuro checks overnight in the ICU and he improved and was transferred to floor. His mentation continued clear. Blood cultured drawn 12-22 returned positive for staph epidermidis times 2 -> most likely contaminant. He did meet SIRS( Systemic Inflammatory Response Syndrome) criteria with CBC < 4 and heart rate > 90, although upon review of his medical record his leukocytosis is chronic. he was given dose of vancomycin and BCx redrawn with NGTD -> ID evaluated patient and antibiotic were deescalated . TSH elevated normal T4.

Date: ________ Student Name: ____________________________ Clinical Site/Unit: ___________________________

Clinical Site Instructor:__ ____________________________Previous Shift Report: ____________________________

Client Initials: _______ Client age: _______   Gender: _____________ Height: __________ Weight: ______________

Allergies: ______vicodin __________________________ Code Status: _________________ Transfer Status: ______________

Marital Status: _____________ Religion: _________________ Occupation: ___________________________________

Cultural Background: ____________________________     Primary Language: _______________________________

Diet/Nutrition: ____________________________   Activity: _______________________________ Fall Risk: Yes / No

Use of (type/amount/frequency): Alcohol: _____________ Tobacco (pack years): ______________________________

Medical Diagnosis(s):

Admitting Diagnoses to Acute Care Facility

1._____altered mental status _______________________________ 2.______________________________________

Primary Diagnoses for Admission to TCU/LTC

1._____acute toxin encephalopathy ________________________________ 2.____ Systemic Inflammatory Response Syndrome_________________________________

3._____sepsis ______________________________4.______stap.epidermis _______________________________

Secondary Diagnoses

                                                1.____chronic pain __________________________________ 2._______ _____________________________

3.________traumatic brain injury _______________________________ 4._confusion__________________________________

Surgical History 1.______________________________________ 2.___________________________________

                                                3._______________________________________ 4.___________________________________

Treatments: _______________________________  IV/Tubes/Ostomies: ______________________________________

Dressings/Wounds: (type & location) ___________________________________________________________________

Oxygen: (delivery method & amount) _______________________________ Dialysis: ___________________________

Recent LAB Results:

Why is this lab significant for this client’s condition? If the lab result was abnormal, include what the NURSE needs to monitor for or do related to the abnormal lab result under the significance column.

Date          Test                     Normal Value                   Client Value                       Significance

          Wbc           4-10                    4.1 ________________________________________________________________________________________________________________________________RBC                    3.80 -5.40            4.95 ____________________________________________________________hematocrict 35.0- 47.0            37.5

Mcv           80-100                76    

______________________________________________________

MCH  2                 7-34 –                                                     22

___________________________________________________________________________________________________

PLT

___________________________________________238________________________________________________________

Recent Diagnostic tests: (list X-rays, CT scans, MRIs, ECGs, Ultrasounds, Cardiac Catheterizations, etc.)

List the test, the test result, and include an explanation of the significance of the results in relation to the medical treatment, other diagnostics, and nursing considerations/interventions for your client. ____________________________________________________________________________________________________________________

PATHOPHYSIOLOGY:

For the primary admitting diagnosis to the acute care facility and primary diagnosis for the TCU/LTC, provide a 3-5 sentence explanation of the pathophysiology of the problem. Then complete an ATI template for the above four diagnoses (4 total).  Use the “Active Learning Template: Systems Disorder” template from ATI Active Learning templates.  Complete, print, and attached to paperwork

PATHOPHYSIOLOGY CONTINUED:

For the top two secondary diagnoses, write a 1-2 sentence explanation of pathophysiology of the diagnosis and explain how this secondary diagnosis may impact your client’s condition during this hospitalization. 

If your client is post-surgical, what problems or complications could possibly occur? What nursing assessments would you need to include in your post-operative or post-procedure monitoring

PATHOPHYSIOLOGY CONTINUED:

 4 secondary diagnoses, write a 1-2 sentence explanation of pathophysiology of the diagnosis and explain how this secondary diagnosis may impact your client’s condition during this hospitalization. 

                    Medication

(Include dose, time, route, & frequency)

       Classification

What nursing considerations should

you include with this medications?

Buspar  15mg

Baclofen 20mg

Cymbalta 30mg

Levetiracetam 1000mg

Omeprazole 20mg

Robafen 100mg /5ml

Senna 8.6mg

Tizanidine hcl 2mg

Xarelto 20mg

Oxycodone HCL 5mg

ibuprofen

Medication Data Sheet

List all scheduled medications for your shift

Drug Name and Classification, Normal Adult Dose, Route & Schedule

Indications for Use and Expected Actions

Side Effects/ Adverse Reactions

Drug and Food Interactions

Nursing Administration Considerations

Client education &

Evaluation of Medication Effectiveness

Ticagrelor

Atorvastin

Pantoprazole

HumLIN  insulin regular

Diclofenac

NURSING PROCESS

Write 2 complete Nursing Diagnoses based on your client problems you noted on your assessment for this day.

Nursing Diagnosis #1:

___________________________________________________________________________________________________

Client Goal: ________________________________________________________________________________________

List 2 priority nursing interventions related to this diagnosis with the rationale for each intervention.

1.       _______________________________________________________________________________________________

Rationale: _________________________________________________________________________________________

Outcome Assessment: ________________________________________________________________________________

2: _________________________________________________________________________________________________

Rationale: _________________________________________________________________________________________

Outcome Assessment: ________________________________________________________________________________

Nursing Diagnosis #2:

__________________________________________________________________________________________________

Client Goal: ________________________________________________________________________________________

List 2 priority nursing interventions related to this diagnosis with the rationale for each intervention.

1.       ______________________________________________________________________________________________

Rationale: _________________________________________________________________________________________

Outcome Assessment: ________________________________________________________________________________

2. ________________________________________________________________________________________________

Rationale: ________________________________________________________________________________________

Outcome Assessment: ________________________________________________________________________________

Post-Clinical Education:

Provide the group with education on a topic you learned about preparing for your client/clinical packet.  For example a medical diagnosis, intervention, medication, lab value, treatment method, etc.  Use this space to write your speaking notes and reference(s).

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