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’s Data collection Day Nurse’s Data Collection Day #1 and/or Day #2
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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:
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
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
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
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
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
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
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 ____
RUE ____ LUE ____ LLE ____ RLE _____ Periorbital_____ Sacral______
JVD: : Y N
History or current alterations affecting this system:
Possible Nursing Dx:
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:____________________________
History or current alterations affecting this system:
History or current alterations affecting this system:
Possible Nursing Dx:
Nutrition
Adm. Weight: ________Current Weight:_______Ideal Body Weight:____History of Weight loss: ___________________________________________________________________
Physical Assessment - Data Collection Day of Care# 2 Vital Signs:___________________________
Neurosensory
History or current alterations affecting this system:
Possible Nursing Dx:
Musculoskeletal
History or current alterations affecting this system:
Possible Nursing Dx:
Respiratory
History or current alterations affecting this system:
Possible Nursing Dx:
Cardiovascular:
History or current alterations affecting this system:
Possible Nursing Dx:
Gastrointestinal
History or current alterations affecting this system:
Possible Nursing Dx:
Genitourinary
History or current alterations affecting this system:
Possible Nursing Dx:
Integument
History or current alterations affecting this system:
Possible Nursing Dx:
Nutrition
History or current alterations affecting this system:
Possible Nursing Dx:
Pain Assessment:(describe)
History or current alterations affecting this system:
Possible Nursing Dx:
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.